THE YOUNG MAN sitting in my examination room is tall, lean and terribly appealling. He looks at me mournfully and, with one of those eloquent shrugs the French manage so well, asks, "But, doctor, what am I to do? I am too thin -- like a boy still. I want you to prescribe me hormones."
Inwardly, I gulp. This 18-year-old, with his rugged innocence, would make Burt Reynolds envious. And yet he looks at me out of those discontented eyes, asking to be adulterated. No way. Mother Nature would definitely not approve. But how to convince him of that?
I don't bat an eyelash. "How would you feel about going bald?" I ask. I share with him some information about hair loss in men from excessive testosterone.
Have I read him right? It seems so. He is horrified, and quite content to accept a more benign therapy -- chocolate milkshakes.
I wonder to myself if Hippocrates had to deal with problems like this.
Finding an effective way to cope with the stomachaches, palpitations, dizzinesses, headaches and the list of other concerns that bring people to a doctor isn't easy. Symptoms like these may represent nothing more than the disquieting responses of our bodies or psyches to life's stresses -- but they also may be more serious.
The day-to-day work of making diagnoses, helping people to live with them, and providing appropriate therapy while doing no harm, demands communications skills and scientific acumen. But when it's effectively done, something more is involved as well -- the art of medicine.
Talking about the art of medicine is difficult. It is elusive; it defies formal definition. To some it comes by luck, to others by intuition. It may be hard to get two doctors who practice it well to see it the same way. We try to teach it by example to the people with whom we work at the university hospital. But to learn it requires an open attentiveness that is not always easy to muster during training, when there is so much else to assimilate and you're forced to perform rapidly and effectively for too many hours at a time.
Being psychologically sensitive is important, but it's not everything. Neither is being a technical virtuoso. Even when what matters most is making a physical diagnosis, there are some whose mastery of the art of that process leaves the rest of us feeling like rank amateurs.
A friend recalls making rounds, during his medical training, with a physician famous for his diagnostic skills. The medical team was worried about a feverish, confused young man from an impoverished neighborhood. They had done every test in the books to identify his illness, but had come up empty-handed.
As he stood at the bedside, this physician had the habit of touching the patients, examing them as he heard their stories -- not in an organized way, but almost absent- mindedly. As the team offered the scant information they had gleaned, they were a bit embarrassed to see the physician bemusedly manipulating the young man's genitals under the bedsheets.
Suddenly the doctor brightened up, and at the end of the presentation urged them to repeat several tests, because he was convinced the patient had tuberculosis of the brain.
He was right. When the house staff put it together, they realized he had intuitively considered tuberculosis as a strong possibility in a sick young man from a disadvantaged background. Since there was no evidence of it in the lungs, the doctor had begun -- his hands responding unconsciously to the verbal information he was assimilating -- to search for another place it might be hidden. He had located what turned out to be a tuberculous nodule in the genitals.
What impresses me most is that unconscious processing of information which was obviously occurring even as this doctor listened to the presentation, the way he "lost himself" in the story and the examination, then resurfaced with the answer.
Another very good doctor describes the way he discovered that role-playing is part of his version of the art of medicine. At the beginning of a consultation, he is studiedly neutral. But 15 or 20 minutes into the encounter, he almost intuitively adopts a persona -- a character -- who can deal effectively with that particular individual. He compares the process to the acting he also loves.
The art of medicine, almost by definition, is that which you cannot program into a computer. The question I ask myself is can you program it into medical students? How, in effect, can you get teach them to heal by using the parts of their make-up that are the most human?
It's November 1976. Hunched up in a folding chair opposite me is a grizzled vagabond, a street person who has become a familiar fixture to the hospital staff. He turns up each fall, they tell me, when the weather gets cold and the nights bitter and the Washington streets are no longer hospitable to the homeless poor.
This time he came in escorted by the police, after behaving bizarrely downtown. He had carefully explained to them that he was a regular mental patient at St. Elizabeth's Hospital, where I am studying psychiatry for two months.
Three pairs of eyeglasses are wedged onto his nose. He eyes me curiously through the scratched lenses.
Experiences with patients like him are supposed to teach medical students the theory and practice of medicine. But I'm about to get a bonus -- I begin to find out that you can learn something of its art in the most unexpected places.
I am mentally flipping through those books, trying to figure out what part the glasses play in his craziness -- he has been diagnosed a paranoid schizophrenic. I fantasize that he does not know he's wearing them, or that they have a hidden meaning pivotal to his illness. Only a third-year student, do not really understand schizophrenia. But I am wondering what will happen if I confront him with his puzzling symptom.
No glasses associations pop into my mind. What does, though, is Alice Roosevelt Longworth's description of a visit with the poet Ezra Pound when he was at St. Elizabeth's many years earlier. When she and a friend arrived to see the refractory inmate, Pound presented himself wearing a stack of hats piled on top of one another.
During the visit, the hats were never even mentioned. Mrs. Longworth, after all, did not believe Pound -- who, if he were not in the mental hospital, would have been facing treason charges for his war-time propaganda broadcasts for the Axis -- to be insane. She considered him an eccentric, like so many of her friends, and it certainly would not do to ask an eccentric friend why he wore the clothes he put on, or said what he did.
I am not constrained by such good manners. The man I am interviewing is, after all, certifiably insane, and entitled to his symptoms. But I am new and inexperienced and eager to unravel the tangled thread of his thoughts. When the conversation reaches an awkward pause, I screw up my courage to ask why he is wearing them.
"Oh, these," he chuckles. "You know my eyesight ain't what it used to be, and I don't have no good glasses. I found all these and put 'em together, and now I see just fine!"
Crazy? Like Ezra Pound, maybe. That heap of hats -- or what they were meant to symbolize about the poet -- kept him safely within the walls and gardens of St. Elizabeth's in 1946, and out of a prison cell. And in 1976, at least, those glasses -- or what they suggest about the old man -- not only buy him a warm bed in St. Elizabeth's when the world turns grim outside, but help him see better, to boot.
I thank him politely for his time, but in the years to come I will have good reason to thank him many times for the insight.
Specifically, I learned something that isn't taught in the classroom -- that the only dumb question is the one not asked. But more generally, I began to learn something that can't be taught in class. I began to get an inkling that there was more to being a good doctor than the science. The patients might teach me as much as the staff. The art of medicine is not a "us and them" proposition: it is all of us who come with these very vulnerable bodies and minds, and what someone else suffers today, I might tomorrow.
When a CAT scan or an electrocardiogram does not explain what's going on, and when the Physician's Desk Reference has no easy therapy to offer, that art may involve being able to dig deeply into your own personal experience to get an intimation of what is happening.
A troubled young woman comes to see me because she's having pain and a tingling sensation in her hand. She has been hurrying between Washington and New York for more than a month, trying to cope with the anguish of her mother's recent collapse, caused by what has turned out to be an inoperable brain tumor. The fatigue and strain show in her face.
We talk for a while about her mother's illness, and the family's pain.
I examine her and tell her the symptoms may be related to the stress she's experiencing, or to an old, minor injury, or that they might be caused by a fibrous band pressing on one of the nerves in her wrist. She looks at me as if I've confirmed a fear she is afraid to articulate. I ask her what she thinks is wrong.
"That's what they told my mother when she first saw a doctor. She had the same symptom -- and it turned out to be her brain." Once again I whisper silent thanks to the old man at St. Elizabeth's who convinced me of the importance of asking people what they think is causing their symptoms.
Sometimes an answer zeroes right in on the problem -- "Do you think the 15 cups of coffee I drink every day could be making my heart pound like this?" But even if not, it may help me understand what someone fears the most -- fear that can be addressed if we know what it is, but which can fester and dominate if left unspoken.
This woman, in grieving her mother, is confronting her own mortality -- a natural response and an expression of the vulnerability from which we all suffer when someone we love is ill.
I could send her for a scan, but what would it gain? A careful neurological examination, explained as it is performed, does as much to convince her and me that her symptoms derive more from her heart than from her head.
Tests could be counterproductive as well as costly. They might direct attention away from her more immediate need for empathy and understanding, or from what might be more helpful in the long run -- insight into the meaning of her fear.
What I offer instead is what my own experience, scientific and human, has taught me.
Scientifically, I must know enough about diseases to understand if someone like this young woman is at great risk of having a serious condition. I must also be able to tell, from the nature of her symptoms, how important it is to intervene now with tests or treatment.
Sometimes the answer is clear. If a bellyache feels like appendicitis and behaves like appendicitis and you still have your appendix, someone is likely to take it out. That makes sense. The risk of death if you do not have surgery is so great compared to the risk of the operation -- and the operation is so much safer before an infected appendix bursts -- that no one wants to wait around and see what happens. We are all over-suspicious by training. And it is natural to want to use the technology we've spent so much time and money developing to save lives.
But this time, what I know reassures me that the likelihood of this young woman having a cancer of the brain is so remote that the significance of her symptoms must lay elsewhere. My intuitive response to her pain actually comes to me in a fragment of another of those poems that run through my mind, one in which Gerard Manley Hopkins asked "Margaret are you grieving/Over Goldengrove unleaving?" It suggests that a child mourning the coming of fall is really mourning her own mortality.
I tell my patient that's what I think she's doing as she grieves for her mother, and that it couldn't be more natural or appropriate.
It seems to follow that the doctor who is most skillful at the art of medicine will be the most effective at its practice. Then the question that becomes important is -- just what is it that creates a person who has the potential to be good at the art?
It's 3 a.m., and the phone has been ringing all night.
Calls from the emergency room, from the house staff, from a woman who woke up breathless and frightened. My years of training, and the much more pleasant nighttime encounters with my daughter during her first three months, have left me in good shape for this work. By the time the receiver is back on the hook, I'm usually fast asleep again, and lucky to remember any of it by morning.
But tonight sleep has been disturbed too many times by the insistent telephone, and I'm padding barefoot around the dark house, picking up a stray sock and a handful of Annie's crayons, rescuing my instruments from a tangle of toys, watching a raccoon stalk across the back porch. And, of course, thinking.
What makes any person effective is colored by so many intangibles. I'm not sure that whatever kind of doctor I am hasn't more to do with making funny faces with Annie and singing off-key lullabies than with anything related to formal training.
It's from her and my husband that most of my nurturing comes these days, although interactions with people I care for contribute to it, too. The richness of the support we receive is certainly what gives us something to pass along to others, and I have been lucky in that.
Annie is snuggled against her lamb as she sleeps, and Steve is sprawled out on the bed with his manuscript, finally completed, on the floor beside him. I crawl back in, wondering if we shouldn't choose our potential doctors -- and maybe our lawyers and chiefs, too -- on the basis of how well they've been nurtured, with instructions that whatever else they do, they pass it along.
It would make medical school applications a lot more interesting, and it might not do the profession any harm, either.