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Self 

Chapter:
Self
Author(s):

Nigel Nicholson

and Nathan R. Selden

DOI:
10.1093/med/9780190457488.003.0008
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date: 07 July 2020

Chapter 4 began by noting a difference in the way Hippocratic texts addressed the reader. Some appealed to their readers’ identity as physicians, while others appealed instead to mastery of a discipline without explicitly suggesting that their readers would identify as physicians. In this chapter, we begin with a different rhetorical element of these Hippocratic texts: the construction of the physician’s relationship to his own body.

How physicians relate to their bodies is a significant issue in current medicine. There is considerable concern that, as they age, physicians fail to recognize declining levels of stamina, energy, and memory and fail to keep up with new techniques and innovations, and that more generally physicians are unable to adequately recognize when they are depressed or subject to dangerous levels of stress.1 Such situations clearly threaten the health not only of physicians but also of the patients they care for. Consequently, considerable effort is being put into developing tools that can help physicians better monitor and regulate the physical, cognitive, and emotional demands of the job and better recognize when remedial attention is required or when retirement is necessary.2 This chapter explores elements in the rhetoric of Greek medicine that militate against physicians being able to satisfactorily assess their own bodies and articulates ways in which this rhetoric, still central to self-understanding in medicine, can be overcome. We argue that physicians can develop successful tools for self-evaluation and enhanced wellness that also respect their professional autonomy, as discussed in chapter 5.

Doctors and Bodies in the Hippocratic Corpus

Let us look once more at the case study of Silenus, the Thasian who came down with what turned out to be a lethal fever after exercising at the wrong time. The text of this case study, from the treatise known as the first book of the Epidemics, is reproduced in full here again:

Silenus lived on the main street, near the house of Eualcidas. After hard work, drinking, and exercising at the wrong time, fever took hold of him. He began by having pain in the loins; also heaviness of the head, and stiffness of the neck.

From the bowels on the first day came bilious discharges, uniformly liquid, foamy, dark in color, copious; urine black, having a black sediment; thirsty, tongue dry; during the night he slept not at all.

On the second day, acute fever, increased stools, thinner, foamy; urine black, troubled during the night, he made slight mental errors.

On the third day, all the symptoms were more intense; stiffness of the abdomen, on both sides, rectangular in shape, somewhat loose; stools thin, blackish; urine muddy, blackish; during the night he slept not at all; much talking, laughing, singing; he could not control himself.

On the fourth day, in the same state.

On the fifth day, stools uniformly liquid, bilious, smooth, greasy; urine thin, and transparent; he was slightly in control mentally.

On the sixth day, about the head he perspired a little; extremities cold, livid; much tossing about; nothing came from the bowels, urine stopped, acute fever.

On the seventh day, unable to speak; extremities could no longer be warmed; he did not urinate.

On the eighth day, he was in a cold sweat all over; red rashes with sweat, round, small like acne, persisted, and did not subside; by means of a slight stimulus, thin stools, seemingly undigested, copious, came out, accompanied by pain; urinated with pain, pungent; extremities were warmed slightly; some light sleeping; comatose; unable to speak; urine thin, transparent.

On the ninth day, in the same state.

On the tenth day, he took no drinks; comatose, some light sleeping; from his bowels came the same discharges; he urinated considerable amounts, thickish; when it stood, a white sediment, like coarse meal, in it; extremities again cold.

On the eleventh day, he died.

At the start, and throughout, his breathing intermittent, heavy; constant throbbing in the abdomen; age about twenty years.

Our focus in this chapter is on the style of this report. These case studies have been seen as notes only, not intended for circulation,3 but, whether that is true or not, they do possess a powerful style that asserts a convincing claim to truthfulness, and that style is worth examining.

First, the simple organization (one day at a time), the brevity and unadorned syntax of the notices, the regular omission of verbs, and the impression of precision in the evaluation of the symptoms confer a no-nonsense, business-like quality to the account that makes the entry seem to be purely driven by what happened to the patient. There are no rhetorical flourishes, and the content seems deliberately lowbrow. There is no squeamishness about discussing urination and defecation; indeed, there is some sense that this is one of the physician’s primary subjects. (Figure 7.1 shows a manuscript page from a sixteenth-century Latin translation of Epidemics 1 that focuses on feces; Figure 7.2 offers an artist’s impression of Hippocrates studying a patient’s urine from a medieval illumination.) This account thus seems as prosaic, and as far from poetry, as one can imagine.

Figure 7.1. Page from a Latin translation of books 1 and 3 of the Epidemics, interspersed with commentary from Galen. This page includes a (rather unhelpful) piece of advice from Epidemics 1.11 about the importance of studying a patient’s feces: “Raw and undigested evacuations, and those converted into bad abscesses, indicate either an ambiguous condition, or pain, or a long duration, or death, or relapses.” (Cruda vero, et incocta, atque in malos abscessus conversa, aut acrisias, aut dolores, aut diurnitatem, aut mortem, aut recidivas). From Liber primus et tertius de morbis epidemiis, id est vulgaribus, cum commentariis Galeni, Hermanno Cruserio interprete (The First and Third Books about Epidemic Diseases, that is Common Diseases, with the commentaries of Galen, translated by Hermann Cruser), verso of p. 62. Published by Bernardino Stagnino, Venice, 1538. Wellcome Collection CC BY.

Figure 7.1. Page from a Latin translation of books 1 and 3 of the Epidemics, interspersed with commentary from Galen. This page includes a (rather unhelpful) piece of advice from Epidemics 1.11 about the importance of studying a patient’s feces: “Raw and undigested evacuations, and those converted into bad abscesses, indicate either an ambiguous condition, or pain, or a long duration, or death, or relapses.” (Cruda vero, et incocta, atque in malos abscessus conversa, aut acrisias, aut dolores, aut diurnitatem, aut mortem, aut recidivas). From Liber primus et tertius de morbis epidemiis, id est vulgaribus, cum commentariis Galeni, Hermanno Cruserio interprete (The First and Third Books about Epidemic Diseases, that is Common Diseases, with the commentaries of Galen, translated by Hermann Cruser), verso of p. 62. Published by Bernardino Stagnino, Venice, 1538. Wellcome Collection CC BY.

Figure 7.2. “Hippocrates examining urine” (demonstrating uroscopy and cautery). Roland Parmensus, Chirurgia, Rome: Biblioteca Casanatense MS 1382, folio 2 recto. Wellcome Collection CC BY. Detail of the original.

Figure 7.2. “Hippocrates examining urine” (demonstrating uroscopy and cautery). Roland Parmensus, Chirurgia, Rome: Biblioteca Casanatense MS 1382, folio 2 recto. Wellcome Collection CC BY. Detail of the original.

Second, the sense of precision is increased by a certain regularity in the description. The physician seems for the most part to be following a standard protocol in his assessment of the patient each day. Each day the same questions are asked—the patient’s temperature (feverish? sweating? cold fingers and toes?); any changes to the body (distention, rash); the quality of the patient’s feces and urine; how well the patient slept; what the patient ate or drank, if anything; the patient’s mental state or abilities—and often, though not always, in the same order. The physician seems to follow a method, which makes the assessment look scientific. Moreover, certain elements of the process are revealed when relevant—for example, cloudy urine is allowed to stand to see if a sediment collects—which gives the impression of a much more significant methodological edifice of which we are only seeing a small part.

Third, the account is entirely dispassionate. No sympathy or concern is expressed toward the patient. The physician is represented as uninvolved emotionally with the patient and perhaps even seems lacking in feeling.

Finally, and most surprisingly, the physician is represented not just as uninvolved emotionally but uninvolved as a doctor. W. H. S. Jones speaks of the physician as “acting not qua physician but qua scientist; he has laid aside the part of healer to be for a time a spectator.”4 The physician does not refer to himself. There are no first-person pronouns and no first-person verbs, and he seems to do nothing but record the progress of the illness. It is important to recognize that this is just the impression conveyed by the account, however.5 While the author’s aim is to provide an account of symptoms so that other physicians can predict the course of an illness,6 it is in fact clear that the physician does intervene in certain ways, or at least has an attendant intervene. This is clear from other case studies that speak of pessaries and suppositories being administered7 and, in fact, clear from this case study too. On the eighth day, after all, an enema is administered (“by means of a slight stimulus, a copious discharge from the bowels”), while on the seventh and eighth days it is made clear that efforts have been made to warm the patient’s hands and feet (“extremities could no longer be warmed,” “extremities were warmed slightly”). What is noteworthy is that the agency of the enema and the warming is completely obscured; the physician does not say, “I applied a slight stimulus,” or perhaps “I had attendants rub the feet,” but leaves himself out of the account.

The effect of this strategy is to locate the physician on a different narrative level to that of the patient. The patient is on the level of what is narrated, of the events that happen, but the physician is a step above, on the level of the narrator, telling the story of what happened but not part of that story and not a character in that story. Again, this is a literary effect; the physician could have been a character in this story—could have been revealed as administering the enema, or as interacting with and observing the patient during the illness—but a choice has been made to keep patient and physician on a different narrative level.

The Hippocratic physician certainly has a bigger role in the more theoretical parts of the treatises. In the narrative sections of the Epidemics, which describe the fevers as single phenomena, the narrator occasionally appears but crucially in the role of someone providing evidence or evaluating the evidence. On six occasions in Epidemics 1 and 3 the narrator makes clear that his knowledge is limited (“Of those that were laid up in bed, I do not know of any who survived even a moderate amount of time,” “I know of none of these that died,” “I know of none that died if there was a significant bleeding,” and so on).8 He draws attention to his memory once (“I will recall”), to his experience once (“such as I had never encountered”), and to his judgment three times (“the factors from which I made my judgment,” “I consider a significant part of medicine,” “it seems to me”).9 It is worth noting, however, that the narrator is largely absent, and occasionally clearly suppressed, with passive verbs (e.g., “will be described”) in place of active (e.g., “I will describe”).10 In other, more argumentative treatises, the physician appears more frequently in the text but as someone who proves, explains, advises, and engages with other physicians and their theories, not as someone directly interacting with patients.11 In these combative contexts, the authors assert themselves so strongly that Geoffrey Lloyd speaks of an egotism in their typical style.12

The physician is thus clearly framed as a narrator of sick bodies but not as handling or interacting with them—not as a participant in their stories. There is, in fact, a profound separation that is suggested here between the thing, the object, and the subject that tells its story. This distinction easily shades into another, that between the body and the mind. The physician is the mind, the active organ of thought and analysis, while the patient is the body, the passive material that suffers.

This framing of the physician’s work makes it hard to find a place for the physician’s own body. The patient has a body, but, as mind, the physician is separated from that physical world, studying the sick but not falling sick; he is a mind, not a body. Brooke Holmes speaks of the Hippocratic physician as “disembodied,” as seeming to lack “a body that would implicate him in the world described by the text.” The egotism of the physician’s self-presentation as an expert judge and narrator is accompanied by a failure to acknowledge “that the expert on the physical body has a body of his own.” “What is missing from these texts, in other words, is the idea that the physician has a body susceptible to the forces that he masters in others. Disembodiment defined in these terms appears to be one of the essential features of medical authority in the Hippocratic texts.”13

The Disembodied Physician and Thucydides’ Description of the Plague

The tension that can result from this disembodiment of the physician is starkly visible in one of the most extraordinary moments in Greek literature, the description of the plague that struck Athens by the historian Thucydides (Figure 7.3).14 Thucydides adopts a similar posture of disembodiment to a Hippocratic author in his writing of history. When he discusses his method and his gathering of evidence, he speaks in the first person, with first-person verbs or first-person pronouns, and often does so combatively.15 Unlike the Hippocratic physician figure, however, Thucydides is also a character in his story, since he was an Athenian general involved in an important campaign against Brasidas, who was, unfortunately for him, Sparta’s most imaginative general. Yet when Thucydides describes his own actions as a general (i.e., as a character within his own story), he speaks of himself in the third person, not the first, almost as if he is someone else: “Thucydides and his ships arrived at Eion late on the same day.”16 He does identify himself as the author of the work at the beginning of this episode but only does so in the third person, thus imposing a strange distance between Thucydides the first-person narrator and Thucydides the character in the story: “Thucydides, the son of Olorus, he who wrote these things.”17 In fact, he regularly speaks of himself as author in the third person.18

Figure 7.3. Bust of Thucydides. The bust is a plaster cast taken from a Roman copy of a Greek original dating to the early fourth century bce. The plaster cast belongs to the Russian Academy of Arts, and the Roman bust can be found in Holkham Hall in Norfolk, UK.

Figure 7.3. Bust of Thucydides. The bust is a plaster cast taken from a Roman copy of a Greek original dating to the early fourth century bce. The plaster cast belongs to the Russian Academy of Arts, and the Roman bust can be found in Holkham Hall in Norfolk, UK.

Photograph by shakko (CC BY-SA 3.0), via Wikimedia Commons. Retrieved January 12, 2018, from https://upload.wikimedia.org/wikipedia/commons/1/19/Thucydides_pushkin02.jpg.

At one point, all three kinds of self-reference—discussion of his method, a signature of authorship, and a reference to the facts of his political life—are merged:

These things too Thucydides the Athenian wrote down in order . . . and I lived through the whole period, seeing it in the prime of my life, and applying my mind so that I would know things accurately. And it happened that I went into exile for twenty years after my generalship at Amphipolis, and being present at the business of both sides—no less among the Peloponnesians because of my exile—was able to take time to learn about each of them more accurately.

Notice here that the verbs shift from the third person (“Thucydides wrote”) to the first person (“I lived”) and that the description of a political event in Thucydides’ life is subsumed within a discussion of method and thus appears in the first person. The exile is not mentioned at the moment it was handed down by the Athenian people but as an additional fact that helps us to trust Thucydides’ reliability as a narrator.

This combination of first and third person, of narrator and character, is jarring, but not as jarring as the combination that occurs in Thucydides’ moving and disturbing description of the plague that first fell upon Athens in 430 bce (Figure 7.4).19 In the medical tradition plagues provide something of an opportunity. Great physicians like Hippocrates and Empedocles are said to have healed plague victims or driven away plagues or refused to do so (Figure 2.2), though all these hagiographic claims about ancient doctors should be taken with a strong pinch of salt.20 Many victims of this plague are said to have been cured by Acron, a Sicilian physician who seems to have been one of Empedocles’ political enemies, who advised the kindling of fires to purify the air around victims.21 But from the political point of view, plagues could be disastrous, and this plague represented a significant setback for Athens’ imperial ambitions. It struck the city right after the beginning of the Peloponnesian War against Sparta, and, as Thucydides tells it, undermined the state’s self-confidence and faith in its leadership and led to a breakdown in public morals that, for Thucydides, was the typical result of the general population of a city being subjected to significant pressure.

Figure 7.4. The Plague at Athens, oil painting attributed to Nicolas Poussin and now in the Gallery of Sir Frederick Cook, Richmond. Wellcome Collection CC BY.

Figure 7.4. The Plague at Athens, oil painting attributed to Nicolas Poussin and now in the Gallery of Sir Frederick Cook, Richmond. Wellcome Collection CC BY.

Thucydides describes the great Athenian plague much like the author of Epidemics 1 and 3 describes his plagues, focusing on the symptoms of sufferers and how they progressed rather than the causes of the plague and using a vocabulary recognizable from these authors22:

First did severe fevers in the head, redness and inflammation of the eyes take hold, and their insides—the throat and tongue—at once became bloody and emitted strange and foul breath. Next after these things came sneezing and hoarseness, and soon the pain passed into the chest with a violent cough. And when it became fixed in the stomach, it upset it, and then came whatever evacuations of bile have been named by physicians, and with considerable suffering. Empty retching fell upon most, bringing violent convulsions; in some it abated after that, but in others it only abated much later. The surface of the body was neither excessively hot to the touch nor yellowish, but reddish, livid, and breaking out with small blisters and lesions. Their insides burned so much that they could not stand putting on even light clothes or garments, or do anything else than be naked, and most happily would throw themselves into cold water. Many of those who were not tended even jumped into wells under the grip of their insatiable thirst. Drinking more or less made no difference. Throughout it was impossible to be at peace or sleep. For as long as the disease was at full strength, the body did not waste, but, against expectation, withstood the suffering, with the result that most were killed in nine or seven days by the interior burning while they still had some strength, or, of those that escaped, as the disease passed down into their bowels, and severe ulcers developed there and completely liquid diarrhea at the same time fell upon them, many died later, after the disease had gone, through weakness. For the disease, sited initially in the head, passed through the whole body, starting at the top, and if anyone survived after these great trials, the seizure of his extremities marked him out. For it attacked the genitals, fingers and toes, and many survived deprived of these, and some even deprived of their eyes. Others when they recovered were immediately seized by a lack of awareness of everything alike, and knew neither themselves nor those close to them.23

What makes this description of the plague extraordinary reading is how it is introduced24:

I will describe what [the disease] was like, and I will lay out the symptoms from which someone may recognize it, if it ever descends again, and most be able to have some foreknowledge and not be ignorant of it, having suffered from the disease myself and having seen others suffering.

The entirely unexpected introduction of Thucydides’ own body into the narrative is stunning and made more stunning by its brevity. Thucydides simply notes that he contracted this plague and goes on to describe it.

As Brooke Holmes argues, this rhetorical move is simply not part of the Hippocratic rhetoric. In the huge corpus of writings, there are some moments where a physician acknowledges that his body might be vulnerable to disease, but they are vanishingly rare.25 What Thucydides has done is break the rules governing the description of disease, and, indeed, this rule-breaking is surely correlated with his recognition of a truth that seems to have escaped the Hippocratic doctors, or perhaps been suppressed by them: that these plagues were contagious, that doctors were particularly vulnerable to the disease because they came into close contact with it, and that patients who survived gained immunity from it.26 It may seem incredible that the Hippocratic doctors did not recognize the possibility of contagion, but this is another example of the power that rhetoric can wield over the formation of medical theory and practice.

At the same time, Thucydides actually remains fundamentally bound by the Hippocratic rhetoric of disembodiment. The reference is brief and passes swiftly. There is no sense of Thucydides’ pain or suffering, and Thucydides does not express sympathy for himself. Almost no information is provided; he tells us nothing about his body specifically. Did Thucydides lose his fingers, toes, or genitals to the plague? We are not told. This is not the story of his body but of the plague that fell upon Athens and the bodies it infected.

Moreover, and crucially, Thucydides’ body actually appears less on the level of the story than on the level of the narrator; much like the revelation that Thucydides was exiled, the revelation that he contracted the plague is offered only within the introduction to his account of the plague-ridden body, in an argument for why Thucydides’ account should be understood as particularly truthful. It is because Thucydides contacted the plague and saw others suffering from it firsthand that his account should be believed. The fact that Thucydides’ tells us that he had the plague is (at least represented as) more about establishing his truthfulness than describing his body.

The rhetorical pose of disembodiment is thus, in fact, largely preserved. We still find here a mind (Thucydides the historian) describing a body (the body of the plague sufferer), a first-personal narrator describing a third-personal object, and a clear gap between them. Thucydides’ own body quickly disappears into a broader account of the plague, and what is described, in the third-person, is the generalized body of the plague sufferer. The historian’s body looks for a moment as if it will become an event in the story but is corralled within a discussion of method. The complicated boundaries between the mind of the expert and the body of the patient, between the assertive self-presentation of the expert and the distanced third-person treatment of the author-as-character, are thus maintained.

What results for the modern reader is odd and somewhat disturbing: a clinical description that is at once both personal and impersonal or, better, that imposes a dispassionate third-personal narration upon first-person personal suffering. It is the separation between the personal and the clinical that makes this passage so extraordinary: Thucydides describes his own sickness from the outside, as if it is someone else’s.

Thucydides’ description of the plague thus shows us the power of the rhetoric of disembodiment for the physician, its strangeness, and its risks: the physicians’ dissociation from their own bodies, their lack of investment in their own bodies, and the failure to acknowledge the vulnerability of their bodies and their own fundamental physicality. As we shall see, this danger manifests itself both in the physicians’ capacity to recognize and understand patterns in the occurrence of disease, as well as their ability to promote the interests of patients by recognizing and responding to illness and underperformance in themselves or in other physicians.

Brooke Holmes argues that this rhetoric of disembodiment developed in response to the very specific historical conditions in which physicians found themselves in the late archaic and early classical periods: the fundamental requirement placed on many physicians that they establish their credibility by performing before an audience, rather than, say, by displaying a degree or successfully healing patients.27 In these contexts, removed from the immediate context of treating a patient, physicians sought to establish their authority through broader, theoretical claims about the body and human nature through the deployment of a certain kind of vocabulary and through occupying the position of an expert or of a narrator of the body rather than playing a character in its drama. As Holmes notes, such a performance had a very physical component—dress, gestures, expressions, bearing—but any physical component was reduced in relation to that of the pose of the expert or narrator, defined by his ability to argue about theory and tell the story of the body. Moreover, as Holmes notes, as the arena for this self-promotion came to include texts, the physical component was further obscured, and the physician’s distance from the clinical encounter increased. The very writing of the Hippocratic treatises thus seems to have encouraged the physician’s dissociation from the body, both his patient’s and his own.

That the physician’s self-representation as an expert without a body owed its creation to a specific historical moment and a specific set of social circumstances should help us reflect further on its oddity—there was nothing natural about this development—but that does not lessen its influence. As Holmes suggests, the rhetoric of disembodiment that developed in this context may well be a foundational moment in the construction of authority in Western medicine.28 It is always dangerous to make sweeping claims, but it does not seem wrong to assert that the idea of the disembodied physician still exercises a strong influence today. Evidence shows that physicians are surprisingly poor at recognizing the needs and condition of their own bodies, whether recognizing when they are dangerously stressed, burning out, or experiencing a diminution of their faculties. We suggest that this is another problem that is partly a problem of rhetoric, a rhetoric that drives a wedge between the expert physician and his or her body and discourages or militates against identification with it. In the final section of this chapter, we consider various tools and methods for undermining the power of the rhetoric of the disembodied physician and protecting the health of both physicians and their patients.

Disembodiment, Stress, and Burnout

Modern doctors are notoriously bad at seeking needed personal care and following their own advice. Physicians in general and surgeons in particular are proud of their ethic of working at all hours, sometimes beyond exhaustion. Physicians tend to idealize their function of understanding the illnesses of others, reaching a diagnosis, communicating a prognosis, and—at least in some cases—prescribing a treatment. At the same time, they fail to recognize the vulnerability of their own physical bodies, until illness or personal failure makes the fictiveness of the disembodied physician impossible to ignore.

The evidence documenting the vulnerability of physicians to illness and burnout is extensive.29 Physicians are more likely than non-physicians of similar age and background to suffer from burnout, depression, or mental illness in general.30 Future doctors enter the profession at the start of medical school with the same rate of depression as the general population but quickly develop rates that exceed their peers.31 Doctors are also less likely to seek care for mental health problems than other professionals. This deficit is particularly poignant, given the rhetorical tendency to frame the professional physician as an expert mind rather than a whole physical being. Because the physician’s mind is the essence of his or her professional identity, intellectual or emotional defects are often seen by doctors as professional as well as personal failures.

Prometheus Bound, a tragedy collected among the works of the fifth-century Athenian tragedian Aeschylus, casually refers to the despair of the physician who has “fallen into sickness, and cannot discover for himself the medicines with which he can be cured.”32 Today, too, the existence of physical or personal limitations in physicians is a source of shame. For example, in the perceived interest of transparency and public disclosure, physician behavior is reported publicly by state medical boards, and restriction or removal of professional privileges is a common result of behavioral illness in physicians.

Physicians are unlikely to seek formal diagnosis or care for mental health problems. There are many barriers, including doctors’ imposing work schedules that both increase stress and compete with time and energy available for self-care. Although US physicians in training are mandated time for self-care, such as dental appointments, medical check-ups, or counseling, they frequently do not use the assigned time due to concern for leaving patients they know well to be covered by another physician or worry about imposing extra duty on a colleague. Behavior is no different at the highest reaches of medical leadership. More than two-thirds of US medical school deans fail to visit their own personal physician.33 Physicians also suffer from a tendency to self-treat and may even inappropriately self-medicate by taking advantage of their direct access to prescribed or misappropriated medications. Certain specialties, such as anesthesia, are particularly vulnerable to medication misuse due to ubiquitous access in their immediate work environment.34

Physicians are also perfectionists, with a high expectation of being able to control or at least predict medical outcomes and to consistently optimize personal performance.35 Based on their experience with a system in which they exceeded expectations at every level of education and training, they may set high or even impossible standards for themselves and risk significant disturbance or despair when they fall short of these goals. Indeed, not just depression but also suicide is more common in doctors than in the general population. Physicians fear the stigma that can follow the occurrence of mental health problems or of seeking treatment.36 Implicit in these attitudes is the feeling that illness represents a weakness, particularly when that weakness occurs in a professional with the intellectual capacity to diagnose and treat such illnesses in others. Physicians, and even those around them, may interpret their own illnesses as direct evidence of professional failure.

Of course, doctors are embodied individuals who suffer the same vulnerabilities as the lay citizens they treat. Ironically, unreflective dedication to their professional duties causes stress that exacerbates these normal human vulnerabilities in ways that ultimately harm not only the physician but also the patients they are trying to treat. Excessive work, stress, fatigue, and exposure cause burnout, which in turn severely degrades the doctor’s ability to care for others. Burned-out physicians are irritable and more likely to make errors in prescribing medication or during surgery. Because of fatigue, irritability, and short tempers, they are also perceived by patients as less capable, knowledgeable, and caring. Finally, burned-out doctors are much more prone to lapses in professional behavior, such as yelling at nurses or colleagues, using alcohol to excess, failing to complete work related duties, or missing work shifts. These lapses are, in fact, among the most common prompts leading to the diagnosis of physician burnout.37

Exacerbating the problem of the burned-out or impaired physician is the tendency of doctors not to hold each other accountable or to report impairment in colleagues. This is due in part to physician’s respect for professional independence and self-regulation and undoubtedly also due to a fear about having similar critical evaluation applied to oneself. Furthermore, the penalty for calling a physician’s behavior or performance into question can be steep, including a loss of referrals or reputation. The ethics committees of some professional medical societies, for example, expend most of their effort censuring doctors who testify against other physicians in medical malpractice cases.38 Conversely, creating nonjudgmental systems of quality tracking and improvement, administered by participating physicians, promotes transparency and accountability and lessens the chance of a catastrophic loss of professional privileges due to a progressive, unchecked degradation of performance. These systems trade the traditional unfettered—and largely unrealistic—ideal of physician independence for a collaborative professionalism that requires personal regulation and growth and offers support. Nevertheless, cultural and even generational changes are likely necessary to reassure physicians that such collaborative systems are in fact safer, and can be more comfortable for highly trained professionals, than the status quo.

Medical education has in general eschewed physician wellness, personal health, resilience, and career development in favor of a narrow and at times perhaps obsessive focus on the technical aspects of patient care, the pathophysiology of disease, and the related underpinnings of physiology, anatomy, and pharmacology. Thus, even today, American medical students are much more likely to learn the biochemical reactions of the Krebs oxygenation cycle (a piece of biochemical trivia that is fundamental but virtually useless in day-to-day medical practice) than how to recognize and intervene when an impaired or exhausted colleague is putting patients at risk. This pedagogical preference may reflect the historical choice in early-twentieth-century American medicine to create a very intensive system of doctoral-level training as a prerequisite for practicing even general medical care. American physicians must earn a doctor of medicine (MD) degree, based on four years of undergraduate plus four years of postgraduate study. This choice was part of the reform of US medical education proposed by and implemented after the 1910 Flexner report in response to tremendous variability in the length, character, and quality of nineteenth-century medical education (Figure 7.5 shows a portrait of Abraham Flexner, author of the report). The US system stands in contrast to the British paradigm of medical education, which is also in place throughout the Commonwealth and is influential in many other parts of the world. The majority of British physicians earn a bachelor’s degree in medicine and surgery (MBBS) in six years. On the basis of their doctoral degree, American surgeons are called “doctor,” while British surgeons are generally referred to as “mister.” American medical education at the doctoral level has been particularly disdainful of curricular content focused on the practical aspects of medicine, such as the business of medical practice, assuring patient satisfaction as well as good medical results, managing employees, leadership training, professional development, or physician health and wellness.

Figure 7.5. Abraham Flexner, author of the 1910 Flexner Report.

Figure 7.5. Abraham Flexner, author of the 1910 Flexner Report.

Photograph by Edward Klauber. Public domain, via Wikimedia Commons. Retrieved October 18, 2018, from https://commons.wikimedia.org/wiki/File:Abraham_Flexner,_head-and-shoulders_portrait,_facing_left)_-_Klauber,_photographer_and_art_dealer,_Louisville,_Ky_LCCN91788348.tif.

Two factors are driving change in this important area. First, the popular representation of physicians has increasingly included a more honest portrayal of physical and personal impairments, failure, and vulnerability. The idealized portrait of the 1950s physician Marcus Welby MD has given way to more realistic depictions of ill or impaired physicians. Honest, first-person accounts of physicians with serious illness, once startling, are now increasingly common. These include the 1980s autobiographical account of a self-centered cancer surgeon who himself developed a life-threatening cancer and had to suffer through the impersonal and technical care he had delivered throughout his own career to patients.39 The influential book was made into a hugely popular Hollywood movie, The Doctor, which engendered extensive discussions about the role of physician as patient. More recently, a senior neurosurgical resident trainee, husband, and father in his final months of life wrote an award-winning and stunningly poignant description of his experience of incurable cancer and the lessons he learned not only about his own mortality but about doctoring.40

These lessons point to the central role of empathy in the experience of caring for ill individuals. The rhetoric of disembodiment impedes a genuine empathy with the pain, sorrow, and fear associated with serious illness. Medical curricula since the 1980s have recognized that patients and their family members seek guidance from physicians for navigating the experience of illness, in addition to assistance with the technical remedies for illness. To this end, these curricula have increasingly included explicit and intentional training in managing these emotive and experiential aspects of patient care. It is not uncommon for young physicians near the beginning of medical school to participate in “patient-doctor” courses, in which they discuss ways to communicate complex information and difficult truths effectively with patients. In the late 1980s at Harvard Medical School, an early proponent of “new pathway” medical education, classmates were videotaped role-playing patient encounters with each other to learn by self-observation how to communicate effectively with patients. A faculty mentor then led them in developing suggestions for improvement, followed by trying again, and ultimately by supervised initial patient encounters. These simple steps, common to many professions, were considered revolutionary in medicine at the time.41

More recently, neurosurgery residents participating in mandatory boot camp courses using a national skill curriculum have watched videos depicting the disclosure of a life-threatening brain tumor diagnosis to the parents of a young child immediately after dangerous and complex surgery. The residents first see the video of a self-absorbed, busy, and distracted surgeon, pressured for time, who makes the disclosure, displays no empathy or insight into the parents’ emotional response, and then moves on to his next patient. In a second video, they see the contrasting example of a compassionate surgeon who, based on experience and training, anticipates the parents’ response, modulates and stages the disclosure, supports them in their initial steps at coping, and engages a social worker to continue next steps while moving on to care for other patients. The neurosurgical residents and a mentor then discuss the videos, role-model the interactions with each other, and provide peer feedback.42 One of the important ideas that invariably comes up in these sessions is recognition and discussion of the physician’s own emotional responses to disclosing such news, how a doctor can be both empathic and resilient over a lifetime of breaking bad news, and the effects of such duties on personal wellness. These exercises, done well, represent the most powerful “embodiment” of the physician as human and utilize that humanity to better serve the patient and sustain wellness in the physician.

Recently physician wellness has also become a major national health care goal. In 2008, in response to concerns about safety, inefficiency, expense, patient dissatisfaction, and poor health care outcomes, the US Institute for Healthcare Improvement (IHI) identified a “Triple Aim” for reforming the national health care system. The IHI Triple Aim is to create health at the population level; to improve patient experience, including quality and satisfaction; and to reduce cost (Figure 7.6). Physicians, government regulators, patient advocates, and other stakeholders soon realized, however, that the Triple Aim was not achievable without adding a fourth aim: clinician wellness. Only appropriately rested, supported, and empathetic doctors can effectively and compassionately care for patients.

Figure 7.6. Institute for Healthcare Improvement “Triple Aim.”

Figure 7.6. Institute for Healthcare Improvement “Triple Aim.”

Reproduced by kind permission of IHI.

Two contrasting strategies have emerged to promote wellness. The first, more traditional strategy focuses on promoting wellness in doctors themselves, particularly by building resilience to burnout. This strategy employs tools such as counseling, recognition programs, and meditation or mindfulness training.43 Although this strategy is likely beneficial, particularly for select individuals, a second strategy appears to be more effective.44 This second strategy focuses instead on reengineering the doctors’ working environment to facilitate their ability to work efficiently and effectively and to eliminate distracting bureaucratic tasks not directly connected to care of the patient.45 For example, automating or delegating the entry of most rote patient data into the electronic health record, so the physician can focus on hearing from and then counseling the patient, is a highly effective intervention.46 In many cases, the initial upfront costs of hiring additional medical assistants for such tasks is more than offset by increased physician productivity.47 Most important, greater focus on humanistic and caring interaction with patients is regenerative and greatly increases physician satisfaction.48 This strategy has been extended in promising early studies to support the lives of highly taxed younger doctors stressed by frequent night and weekend emergency call duties, for example by providing premade meal delivery or home pick-up laundry services.49

Embodiment and the Aging Physician

A special challenge posed by the rhetoric of disembodiment occurs toward the end of a doctor’s career: the decision about when to retire. The disembodied physician might in theory practice effectively until death, like the ancient Greek warrior who battles on unbothered by seemingly serious wounds. The more prosaic truth is that physicians, like all humans, eventually show evidence of degrading cognitive ability or technical skills that limit the effectiveness and safety of their ongoing patient care.50 Some high-risk professions in the United States, such as airline pilots, have limited practice according to age. Medicine has been famously reluctant to do this, in part because medicine resists any external regulation of individual professional privileges. In truth, judging competence strictly according to age is an extraordinarily inaccurate enterprise and risks wasting considerable and precious talent in those with the passion to continue practicing even well into their seventies and who have the mental and physical capability to do so.51 In fact, the US airline industry is currently considering changing from its longstanding practice of age limitation to a continuous system of competence testing that accelerates in frequency with aging. In the case of aviation, competence is fairly narrowly defined and reasonably easy to test using existing flight simulators. This begs the creation of a fair, transparent, and accurate system to assess competence in aging physicians and surgeons that can appropriately balance the physician’s desire and ability for ongoing practice against patient safety.52 Currently, the best systems employ direct peer review and observation. Even these systems, however, are limited by the hesitancy of physicians to restrict the professional freedom of their peers, as discussed earlier. In the future, more accurate immersive simulators may be useful to add objectivity to the ongoing privileging of procedural physicians.

The idea of maintaining competence to practice after training has taken hold in American medicine. These systems, most prominently maintenance of certification (MOC), are required to maintain specialty board certification, which in turn is required to obtain privileges and maintain practice at most US hospitals. In theory, MOC systems could also provide a practical mechanism for assessing existing competencies in the face of aging. In practice, MOC has focused principally on transmitting and assessing factual knowledge, often using online learning tools coupled to periodic objective examinations.53 The professional attestations that make up the other principal component of MOC are notoriously unreliable in assessing ongoing competence, except with flagrant shortcomings that already put local hospital privileges at risk. In addition, resentful of the time and energy necessary to comply with MOC as well as its perceived irrelevance to quality patient care, many US physicians have rejected these systems outright.54 As the public more clearly recognizes and discusses the human fallibilities of physicians in general, and aging physicians in particular, a definitive solution is necessary. Most important is fully engaging physicians in the notion that ongoing maintenance and assessment of true competence, while difficult, is critical for the welfare of patients and to maintain the patient-centered priorities of the medical profession. Convinced of this imperative, many physicians have sought out, designed, and participated in meaningful, generally experiential activities that attempt to deliver on these goals.

In 2007, a group of neurosurgeons of varying ages attending a national conference participated in a structured, interactive exploration of retirement practices for neurosurgeons.55 Recognizing the delicacy and impact of neurosurgical operations, as well as their unusual length and degree of stress, the organizers worried about the lack of an existing standard. Initial polling of the participating neurosurgeons indicated strong preference for continuing the status quo of no regulation. After three non-surgeon experts on aging and performance presented specific data relative to medicine and other professions, re-polling of neurosurgeons reflected a definitive shift in preference to favor regulation by local hospital boards making privileging decisions. At no stage did any neurosurgeons favor government intervention, and few favored national regulation by professional boards as a feature of MOC programs. These results likely reflect a preference among professionals in general, and physicians in particular, for familiar and less threatening local regulation based on the input of recognized peers. However, it speaks eloquently that when faced with evidence about the inevitable, although unpredictable, degradation of competence, neurosurgeons altered their preference to favor local regulation over no regulation. Neither the initial preference for no regulation nor the switch with evidence to a preference for regulation was affected by the individual surgeon’s perceived economic readiness for retirement. This result suggests that surgeons do put patients’ interests first, reflecting the primacy of personal bonds and trust between the doctor and patient.

Of course, for many doctors, a decision between continuing current practice and a precipitous retirement represents a false choice. As they age, many physicians, and particularly surgeons, evolve their clinical practices and more broadly their professional activities to emphasize tasks that require broad experience, leadership skills, and accumulated wisdom, while deemphasizing tasks that require stamina and raw energy.56 Surgical assisting, supervising and teaching residents in outpatient clinics, teaching surgical anatomy to medical students, and consulting are common professional activities for aging physicians who wish to continue their professional engagement and maintain their identities as healers and teachers. Other physicians take advantage of a lifetime of experience and accumulated leadership skills to engage in professional coaching, conflict mitigation, or other counseling activities. Those surgeons who continue to operate may choose to limit the scope of their practice, maintaining deep expertise and facility with a narrower number of procedures or areas of subspecialty practice. Often, they avoid procedures or areas that necessitate unscheduled emergency duties, significant schedule disruption and fatigue, or lengthy or physically challenging operations. However they evolve their practice to compensate for aging, the latest data suggest that patients of older surgeons, in fact, experience very slightly less mortality risk than those of their younger colleagues.57

Around the time it is natural to evolve toward a more focused and contained clinical practice, many physicians predisposed toward and capable of leadership often take on significant administrative roles. In the academic hospital setting, leadership of a residency or clinical department can occupy more than half of an active senior clinician’s time. In both academic and private practice settings, leadership of a specialty group or clinic, foundation board service, or taking on substantial hospital roles—as chief medical officer, quality director, or medical group board member, for example—are crucial to the safe and efficient functioning of medical systems and generally come with defined support to compensate for time devoted to the task. Most important, these positions allow doctors to exercise their professional skills in a broader context than they typically have earlier in their careers. These roles expose physicians to leaders in other areas of skill and training, including business experts and community members of the hospital or medical school board of directors. In some cases, aging physicians engaged in leadership return to the classroom for additional training in business, quality science, regulatory affairs, or other aspects of healthcare. This adult learning often engenders meaningful career satisfaction for individuals who have demonstrated significant academic motivation and success earlier in their lives. In fact, leadership and professional development, at any career stage, are among the most effective tools for enhancing physician engagement and combating burnout.58

Conclusion

The idea of the disembodied physician holds powerful sway in both ancient Greek and modern American medical discourse. Both the physician who described the sickness and death of the Thasian Silenus and Thucydides, the Athenian historian and general who described the ravages of the plague, hover above their narratives as detached observers and dispassionate analyzers of their clinical observations. This approach impedes not just the display of authentic compassion to patients who need it but also the physicians’ recognition of their own personal vulnerability, impairment, or burnout.

In this final chapter, we have again seen the power of a rhetorical element in the self-understanding of medicine—here, that of the disembodied physician—to seriously and often negatively influence not only the way society views and responds to its physicians but also physicians’ self-understanding, behavior, and personal choices. In many cases, these errant conceptualizations and choices lead to significant problems that seriously affect doctors and their patients: burnout, behavioral lapses, loss of compassion and empathy, psychiatric illness, or other physician health issues, substance abuse, or suicide.

Recognizing the influence of this conception of the disembodied doctor enables physicians, patients, and policymakers to take specific and mindful actions to correct it. Supporting physician wellness first requires intentionally creating work environments and expectations that realistically reflect the limitations imposed by the human physicality of physicians themselves. These measures can then be supplemented by efforts to teach and practice resilience and wellness, in a work environment conducive to success. As in chapters 2 and 5, valuing the community is key here. We should truly engage physicians as members of the broader community in which they practice and treat them in the same supportive way in which we expect them to treat other members of that community. By doing so, we can engage and elevate all members of the profession and enhance the quality and outcomes of the work doctors do. In healing the physician, we reinvigorate our commitment to and understanding of health in general.

Notes:

3 Jones 1948.141–2.

4 Jones 1948.144.

5 Chang 2008.224 and n.19 stresses the hands-on work of doctors even during such epidemic situations.

6 Epidemics 1.11, 23–6. See also Horstmanshoff 1990.178–80.

7 It is clear from Epidemics 3.8 that in general the physician was in some way treating the patients to address their painful evacuations under the fever described there. In the case studies themselves, specific examples are alluded to, again impersonally, in Epidemics 1, case study 4, introduction and day eight; Epidemics 3.1, case study 3, day fifteen; and Epidemics 3.1, case study 15, introduction and day seventeen. Epidemics 3.17, case study 8 offers the only example in the work comprised by these two books of the Epidemics where a first-personal form is used, in this case “On the eighth day, I cut his elbow,” that is, in order to bleed the patient, but this odd moment again shows that the doctor was, in fact, ready to perform procedures. Epidemics 1, case study 4, day eleven, also mentions that the patient was being reminded to urinate, presumably by attendants, but this suggests that the physician offered advice about regular evacuations—another form of involvement in the patient’s treatment.

8 Epidemics 1.2, 1.10, 1.14, 1.16, 1.19, 1.20.

9 Epidemics 1.17, 1.23, 3.9, 3.16.

10 Epidemics 1.10, 3.7, 3.12.

11 For example, Regimen 1.1–2, 1.4, 1.9, 3.58, 3.69; Ancient Medicine 1, 2, 3; Airs, Waters, Places 3, 7, 8. Regimen 1.9 is particularly interesting: “For males and females, how each of these things comes to be, I will demonstrate in the forthcoming discourse.” The impression given is that the narrator is neither male nor female but somehow outside of this world and its process of becoming.

12 G. Lloyd 1987.56–70.

13 Holmes 2013. The quotations are from 439, 433, and 432–3.

14 Holmes 2013.432–3 begins with this moment.

15 Compare, for example, 1.22.2: “Concerning what was done in the war, I decided not to [simply] write down those things that I heard from someone who happened to be present or that seemed true to me, but rather those things at which I was myself present or which I learned from others in a situation where I was able to examine each thing as accurately as possible.”

16 Thucydides 4.106.3; see generally 4.104–7.

17 Thucydides 4.104.4.

18 As, for example, at the opening of the work, and at the end of the years where there was significant action.

19 On the (misguided) attempts to identify this plague with a more modern disease, see Holladay and Poole 1979.282–95.

20 The biographical tradition of Hippocrates speaks of him protecting Greeks, including Athenians, from a plague that ravaged Illyria but refusing to help the non-Greek Illyrians. He also, it is said, refused to take money from the Persian king to cure a plague that had struck Persia. See Phillips 1973.187, Smith 1979.215–19, Jouanna 1999.21–33. Empedocles is said to have cured a plague at the western Sicilian city of Selinus; see Diogenes Laertius 8.70.

21 Plutarch, On Isis and Osiris 383C-D; see also Diogenes Laertius 8.65 and Squillace 2012.28.

22 See Page 1953.98, and more generally. “The great majority of the nouns, adjectives, and verbs in [this passage] recur as standard terms, apparently for the most part with the same meanings, in medical writings of the fifth and fourth centuries B.C.” (Page 1953.109). Holladay and Poole 1979.295–300 argue that Thucydides understood two important principles about this plague that Hippocratic physicians failed to grasp about other plagues: that it was spread by contact with other sufferers and that those who survived the plague acquired immunity from that disease specifically.

23 Thucydides 2.49. For the translations of many of the more technical terms, see Page 1953. “Breaking out” translates what may seem a more dramatic image, literally “flowering” in the Greek. This term, however, “is a standard and very common term in the doctors, applied to a variety of swellings and rashes and eruptions” (Page 1953.107), that is, a dead metaphor, so less colorful language seemed appropriate for the translation.

24 Holmes 2013.432 notes that this constitutes “a rare instance of the first-person in the Histories.” The idea of providing a detailed description in order that a future occurrence of the disease might be recognized is familiar from the prognostic texts of the Hippocratic corpus. See Page 1953.98–9.

25 Holmes 2013.444–54. Cf., for example, On the Art of Medicine 7.

26 Thucydides 2.47.4, 2.51.5–6; Holladay and Poole 1979.295–300; Holmes 2013.432. Cf. also Thucydides 2.58.2.

27 Holmes 2013.159–60. For the rhetorical nature of medicine in this period, see Cohn-Haft 1956.56–61; G. Lloyd 1979.89–92, 1983b.81–2, 1987.95–7, 134; Horstmanshoff 1990.181–2; Nutton 2004.87–9; Totelin 2009.93–9, 111–31; Agarwalla 2010; Massar 2010; Rademaker 2010; Mann 2012.8–12; Rosen 2019. See also the Introduction.

30 Lindeman et al. 1996; Shanafelt, Boone, et al. 2012.

31 Givens and Tjia 2002; Shanafelt, Bradley et al. 2002.

32 Aeschylus, Prometheus Bound 473–5.

36 Center et al. 2003, Baldisseri et al. 2007.

42 N. Prose and M. Haglund, “How Should Providers Deliver Bad News?” Institute for Healthcare Improvement, Open School, 2018. Retrieved June 18, 2018, from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/Duke-HowShouldProvidersDeliverBadNews.aspx.

44 L. Schlesinger and J. Gray, “Giving Doctors What They Need to Avoid Burnout,” Harvard Business Review, October 31, 2017.

46 Shanafelt, Dyrbye, et al. 2016.

49 B. Schulte, “Time in the Bank: A Stanford Plan to Save Doctors from Burnout,” The Washington Post, August 20, 2015.

51 Dellinger et al. 2017. Also, R. Cohen, “Should Older Doctors Be Examined, Tested or Forced to Retire?” Reuters Health News, 2017. Retrieved June 2, 2018, from https://www.reuters.com/article/us-healthcare-physician-retirement/should-older-doctors-be-examined-tested-or-forced-to-retire-idUSKBN1AR22K.

54 Cf. K. Eichenwald, “The Ugly Civil War in American Medicine,” Newsweek, October 3, 2015.

58 L. Schlesinger and J. Gray, “Giving Doctors What They Need to Avoid Burnout,” Harvard Business Review, October 31, 2017.