On becoming a good physician

L. Lewis Wall
Washington University, St. Louis, Missouri, United States (Winter 2012)
This is a narrative fiction, and the characters are not a reference to any historical figures.Zeno glanced at the trail ahead of him. He had left the main road a short time before and his destination was now in view, rising up ahead of him to his right.“Ye gods,” he thought to himself, “am I glad to be out of the city. If one more person vomits on my sandals today, by Zeus, I swear I will run naked through the marketplace and jump into the Aegean Sea.” Some days were like that. An epidemic of gastrointestinal disease was sweeping through the city. For days hordes of patients had been coming to his house at all hours, looking for relief. Zeno had a reputation as the best physician on the peninsula, and it was well-deserved. Sometimes, however, it was just a pain.

A goat scampered out of his way as he continued up the trail. He was perspiring slightly and breathing a little heavily as he swung his staff ahead to brace himself for the last few steep paces as he reached the top. On a small bluff a few hundred yards inland from the ocean there was a flat outcropping of rocks shaded by a trio of ancient olive trees. The white sand beach spreading out below him was magnificent. It cut a sharp, clear line between the grasses covering the stony landscape and the clear azure blue of the water. A soft, cool breeze caressed his face. A few white hairs from his long beard wavered gently in the ocean air. He sat down on a smooth flat stone amidst a small cluster of olive trees, his favorite resting-place when he wanted to be alone.

As he rested his head against the cool rock behind him, the sound of falling gravel made him glance to his left. On the trail below, an earnest young man carrying a goatskin satchel hurried up towards him. Zeno recognized him at once: Cleanthes. What was he doing here?

Cleanthes stuck his head around the rock outcropping. “Master Zeno, may I have a few words with you?”

“Cleanthes. How nice to see you. Were you just in the neighborhood and thought you’d stop by?” Zeno asked dryly.

“To be honest, sir, I followed you out here from the city. There are some things I’ve wanted to speak to you about and when I saw you walking out of town, it seemed like an opportunity I couldn’t pass up. May I sit down? Here. I know you must be hungry.”

Cleanthes opened the goatskin satchel and pulled out bread, ripe olives, and an enormous goat cheese. “I came prepared, sir,” he said, with a large smile on his face. Reaching further down inside, he pulled out a large wineskin. “Are you thirsty, sir? It’s Thracian wine.”

Thracian wine? Perhaps young Cleanthes had a bright future after all, mused Zeno. This was just what he needed. It was good that Cleanthes had shown up.

“What’s on your mind, Cleanthes?” asked Zeno, helping himself to bread and goat cheese.

“I want to become a physician.”

“Are you prepared to buy a new pair of sandals every week?” said Zeno ruefully, looking down at his feet. “There are some disadvantages, you know. The laundry itself can cost a small fortune.”

Cleanthes laughed. “I know the problems, Master Zeno. But this is truly what I want to do. I have known this in my heart since I was a small boy. I watched you from the shadows in the corner when you tended my father during his illness. It was long and difficult, but you cured him—by Asklepios!—and gained the devotion of our entire household.”

Zeno studied Cleanthes. He was known to have a quick mind. Zeno had watched him working with Solon and Aristolochus, fellow physicians and colleagues in the city. He was a serious student, an intense observer. He was also steady and sure with his hands and not afraid to get them dirty when required by the situation—and during the past week, by Zeus, there wasn’t an unsoiled physician within a day’s journey of this place. The best physicians were not necessarily the brightest. Swollen with their own cleverness he had seen plenty of young physicians cut corners and make snap judgments with disastrous consequences. The best physicians were not like cavalry, prancing around the edges to the praise and delight of onlookers; they were heavy infantry, marching slowly shoulder-to-shoulder across the battlefield, invincible, indomitable, and terrifying to the enemy. Cavalry could not win a long engagement, and the battle with disease was often a siege, not a skirmish. Was Cleanthes cavalry or infantry?

“Pass me a cup of that Thracian wine. We’ll see if your offering merits the dispensation of any wisdom today.” Zeno took a swallow and smiled. “Well done, Cleanthes! The oracle is open for business! What would you like to know?”

“I have worked with Solon and Aristolochus for some months now, and I have observed many other physicians in the city. Some physicians are clearly better than others, but I’m often not sure why. Everybody makes mistakes from time to time, and if the Fates have decreed the outcome in advance, even the greatest skill will not prevent death. Some of the most popular physicians are not, in my judgment, among the best, and some of the best are not necessarily popular or acknowledged for the skill they clearly possess. I want to understand what makes a good physician so that I may become one myself. Who should I strive to emulate, and why?

“Ah, these are deep questions. You can spend your lifetime contemplating them and still not reach an unshakable conclusion. As the great Hippocrates said, ‘The art of medicine is long, but life is short.’ I am nearly 60 years old now—a good 15 years more than the lifespan allotted to most men—and I have thought about these questions for a long time. The fact that you are already asking these questions so early in your career is good. Cleanthes, do you accept the premise that the good of every craft, trade, or profession is different from others? That what is good in a breeder of horses is different from what is good in a carpenter, a potter, or a musician?

“Yes, that is so.”

“So, then, tell me what is the good of medicine?”

“To promote health, to cure the sick, to comfort those who are ill and set them back on the road to health.”

“Excellent! This indeed is the good that medicine strives to achieve. And if a physician is to achieve this good for his patients, he must possess certain characteristics that facilitate his excellence in this pursuit, must he not? We call these characteristics ‘virtues.’ They are the facilitators, each contributing to the achievement of the capstone good. As the goods of each craft or profession vary, so too do the virtues necessary for excellence. So then we need to inquire what are the virtues in a physician that promote the good of medicine. Where would you begin?”

“Well, I have observed that many of the best physicians have a sort of fellow-feeling, a sympathy, about them.”

“Excellent again, Cleanthes! This fellow-feeling that you speak of is compassion, and it is the first virtue of medicine. In my view, compassion is the very foundation upon which medicine rests. This sympathy with the ill creates in the mind and the heart a desire to help the sick.”

Cleanthes looked crestfallen. “But Master Zeno, isn’t compassion something that the gods either dispense to us or withhold from us at their whim? I fear I lack compassion—in fact, I often find that the sick are very unlovely indeed. If I am not born with compassion, won’t I struggle as a physician?”

Zeno smiled. “You often hear it said that you either have compassion or you lack it, but that is not true. You can learn to be compassionate, just as you can learn to throw wet clay on the potter’s wheel or ride a horse. It is easier for some to do this than for others, but just as becoming an expert potter requires practice, so too does mastery of compassion. Sprinters at the Olympics train hard to master the art of running, which is critical to their success. How strange it is that so few physicians strive to master compassion!”

Zeno cleared his throat and took another swallow of wine. “This is what you must know if you are to master compassion: you must practice it. Recognize that everyone wants to have happiness and to avoid suffering. This is the common denominator of being human. You must concentrate on this each day and especially before you see each patient. Just as an Olympic athlete warms up before competing in the games, so too must a physician exercise his compassion before starting his competition with disease. As you get more adept at this, the precept will become fixed in your mind, and slowly it will transform your outlook on medicine. It takes discipline! This is one of the most important secrets both for successful practice as well as for living a fulfilling life. Nurture compassion and it will nurture you.”

Zeno popped an olive into his mouth, sucking it between his teeth as he glanced pensively at the horizon. Seagulls circled overhead, diving down and skimming the surface of the ocean as the waves rolled onto the beach.

“The twin brother of compassion,” he said, “is mindfulness. Both compassion and mindfulness come from the gods. Through mindfulness you can increase your compassion. Through compassion your capacity to be mindful grows. Mindfulness teaches you to grasp the present moment, to expand your consciousness so that you are aware of each thought, feeling, or sensation. This, in turn, makes you more curious, open, and accepting. As your capacity to focus intensely on the present moment increases, you will become a better diagnostician. You will see things you did not see before. Pieces of puzzles that seemed unrelated will fall into place. You will be able to grasp the clinical nuance and you will become a better physician.”

“Do you understand, Cleanthes? That is why I come up here so often. It is a cool, secluded space. I can sit on my rock, gaze far out to sea, and concentrate on nothing but my mind, letting the thoughts arise and fade away as soon as I become aware of them. As soon as I acknowledge a thought, I let it go. When I have done this for a while, I become one with the stream of my consciousness. Each sensation becomes more intense and more vibrant. I am aware. When I am finished with my mental exercise, my mind is refreshed, my observations keener, my clinical acuity enhanced. Physicians must treat the soul as well as the body.”

Cleanthes looked at him. “What about mercy, Master Zeno? Does a physician need mercy?”

“Cleanthes, mercy is not a virtue for a physician! Mercy is exercised by kings and tyrants. It is a virtue in a judge, but not in a physician. Mercy is the setting-aside of a deserved sentence, the annulling of a penalty justly due. Physicians are not judges of the sick; that belongs to the gods alone. We are there to ease pain, annul suffering, and promote healing, not to judge.”

“And pity? Do you pity the sick?”

“Pity does not belong in a physician, either! Pity is form of contempt. It is disdain in motion, action streaked with loathing. Pity condescends to help. It is unmanly sympathy, unworthy of a physician. Be compassionate, judge not, and do not scorn the sick with your pity.”

“Surely there must be more to medicine than this?” Cleanthes said.

“Of course there is! You must learn patience, Cleanthes! Patience is a virtue you must cultivate, particularly when waiting out a fever. You must also be competent. You must read the Hippocratic writings, and study the ancient treatises. Observe the sick and know how to chart the course of an illness. You must master diagnosis and learn the prognosis of the various fevers and afflictions that beset humankind. You must know where healing herbs grow and master their proper preparation. Understand poisons and how to counteract them, but never, ever use them yourself. Learn physiology and physics. Understand the seasons, the effect of climate on health and disease. Know the stars and what they portend. You must understand diet and exercise, what increases the blood and what turns it black or yellow. You must learn healing physical manipulations—the art of massage is often useful.”

Zeno popped another olive into his mouth and washed it down with more wine. “You must also master technical skills. You may need to set a fracture if there is no bonesetter around, or deliver a baby if there are no midwives nearby. When you are called in the middle of the night to see a bloated, obese merchant, writhing on his couch with belly pain after enjoying himself too much at dinner the night before, you may have to administer an enema, although,” Zeno observed wryly, looking Cleanthes squarely in the eye, “we usually take along an apprentice in such cases.”

Cleanthes grimaced. Solon must have told that story to everyone. It had not been one of his best moments as an apprentice physician.

“From competence you must proceed to trustworthiness. Being trusted starts with the demonstration of compassion and it builds upon your competence. But these two virtues are not enough. Remember, Cleanthes, your patient can remove himself to another physician at any time. Gratitude is often only temporary, but when he trusts you he will be loyal. You build this trust by being loyal yourself, in spite of the abuses you may sometimes have to endure. You will see and hear much in the practice of medicine. You will be called into intimate family circumstances, possibly into circles of power and influence. Do not meddle in their affairs and keep what you see and hear to yourself. A wagging tongue will destroy the reputation of your patients as well as yourself. When you enter a house, keep your hands off the slaves and the servants, male as well as female. In that way lies only trouble. I could tell you sad tales of careers cut short and lives ruined by sexual indiscretion, but as yet I haven’t had enough wine.”

Zeno smiled, and poured himself another cup from the wineskin.

“Two other virtues march arm in arm. They are prudence and courage. Use good judgment. You cannot be prudent if you are not competent. Do not chase wildly after the latest therapeutic fashion from Egypt, just because it is now popular. Test it with time and careful observation. Have solid grounds for your opinions, and once you have determined what is right, stick by it. By the gods, there is nothing worse than a vacillating, pusillanimous physician who gets talked into one course of treatment and out of another by the patient or family when he knows what is proven and efficacious. This takes courage. You must not be afraid to prescribe a harsh remedy when it is called for, and you must be prepared to run risks when necessary. The road back to health is not always strewn with flower petals, either for the patient or for the physician. And cowardice is not attractive either. In the Athenian plague you were likely to get trampled by the physicians fleeing the city themselves.

Zeno cleared his throat. “Justice,” he said, “is also an important part of medicine. Be fair with your patients. They will respect you for it, and you will respect yourself as well. The greatest democracy is not Athens—it is illness itself. In the City of Illness, all men are equal. The King vomits just as lustily as his servant if his stomach is sour or his bowels are gripped with a fever. Just remember to stand to one side when he does so,” Zeno said with a grin.

“I’m overwhelmed by this Master Zeno,” Cleanthes said. “I feel like a juggler in the agora on market day, but instead of onions or oranges, I’m trying to keep all of these virtues up and going at the same time. It just seems impossible. How do you put all of this together?” Cleanthes asked.

“The key to medical practice, Cleanthes, is integrity. The juggler you speak of has mastered a pattern. He understands the necessary relationships between the spheres, and he strives to give each one just what it needs—no more, no less—to maintain it in relation to the other. He does not begin by randomly throwing objects into the air; this will not work, but once he has mastered the patterns of their interrelationships, juggling is a sight to behold. It is consistency, integrity, and sticking to the underlying principles that makes a master juggler wonderful to watch. The same rigorous adherence to principles makes a good physician. When you have integrity, it all fits together.”

Zeno looked at him. “When you reach this stage, Cleanthes, you have phronesis. This is what Aristotle meant by “practical wisdom.” It is the ability to keep all those balls in the air simultaneously, each in its proper relationship to the others, while you go about your daily rounds, attempting to heal the sick.”

Cleanthes exhaled, and let his head fall back against the rocks. It seemed impossible. He wondered how he could ever pull this off. Still, he reflected, a juggler didn’t learn his skills in a single afternoon. Mastering the art of medicine would clearly take persistence.

“Get up, Cleanthes,” said Zeno, pulling himself upright with his staff. “It’s time to get moving. There is much more to be done. There’s a river of diarrhea flowing through the city, and it isn’t just Hercules who has to shovel out a stable.”

Cleanthes smiled. What was it people said about Zeno? “Gruff, but brilliant”—and in a strange way, somehow worthy of emulation. He shook his head and chuckled to himself. Then he picked up his goatskin satchel and hurried down the path after the old man, who was striding rapidly back to the road. A city full of sick folks was waiting for them down below.

 


 

L. LEWIS WALL, MD, DPhil is Professor of Obstetrics and Gynecology and Professor of Anthropology at Washington University in St. Louis. He graduated from the University of Kansas with a degree in anthropology and history and studied social anthropology at Oxford University as a Rhodes Scholar, carrying out field research in northern Nigeria on the traditional medicine of the Hausa people. He has published widely in clinical medicine, international health, medical ethics, and the history of medicine. In addition to his clinical and academic activities, he is the founder of the Worldwide Fistula Fund, a nonprofit charity currently building a specialist hospital for the care of Hausa women with severe obstetrical trauma in Danja, Niger.

 Highlighted in Frontispiece Winter 2012 – Volume 4, Issue 1