SEEING WISELY
“Doc, you remember our handshake? The Nussbaum handshake? First you slap, then you shake, then you slide! It’s the Nussbaum sandshake, the Nussnutt landrake, the Fussbutt bandlake, the Cussbutt taketake!”
Martha is on the unit again, slinging speech, her words clanging off each other in a rhythm only she can follow. She spent decades as a nurse at a hospital across town, but these days she is mostly a patient, either on our unit or in the apartment she shares with her sister.
Once a year she becomes manic. Her mania starts with a walking rhythm. She calls up old boyfriends. Starts writing poetry about the old boyfriends. Then the rhythm accelerates and she stops sleeping. Soon she barricades the door to her bedroom. Her sister pleads with her to come out, sliding tablets of lithium underneath the door, but Martha crushes them under her dancing heels. Her sister calls a case manager or a police officer to coax Martha out of her room. Together they deliver Martha to the hospital, and we bring her back into a rhythm the rest of us can follow.
Twice a year she becomes depressed. This rhythm starts out slow and, unbidden, becomes halting. She falls into stop-time. She calls up no one. She rarely leaves her apartment. She writes nothing. She sleeps around the clock. She leaves the door to her room open but lies on her bed, thick tears salting the nicotine-carved crevices of her face, and eats nothing. Her sister brings her, slump-shouldered, to the hospital, and we try to interest her in life again.
I have been Martha’s physician for all her hospitalizations over the past several years. She is one of our regulars, so, in a way, I know her better than any of her other physicians do. Her outpatient physicians see her quarterly for fifteen-minute visits in which they focus on symptoms and medication effects, but when Martha is on the unit, I see her at least once and often twice a day. Some of the regulars resent being hospitalized and greet me tersely. Others, like Martha, grace me with their affection.
A few hospitalizations back, Martha formalized her affection for me with a handshake. I shake hands with all my patients, but it is usually a simple affair: a firm grip, eye contact, a modest pump, and a surreptitious squirt of hand sanitizer afterward. Most of my handshakes communicate little more than a greeting and a fear of contagion. Martha managed to communicate that I knew her and that she knew me. She called our handshake the “Nussbaum handshake,” or the “dream shake.” Whenever we met, whether she was manic or depressed, she offered me her hand, and I followed her lead. Shake. Slide and shake. Pinky swears. Fist-bump. Explosion. By the end of the handshake, I would know how she was doing. When manic, Martha filigreed the dream shake with hip-shimmies and then repeated it again and again. When depressed, Martha limped through the dream shake: a simple shake and slide could drag on for a minute without ever crescendoing into a fist-bump and explosion. The rest of our interaction simply refined the initial communication Martha made through the dream shake.
One day I was sitting with Martha, and she gave me a drawing. On a piece of construction paper she had written, “The Nussbaum Dream Shake,” across the top. Below the title were numbered instructions for our handshake: 1. Shake. 2. Slide and shake. 3. Pinky swear. 4. Fist bump. 5. EXPLOSION!!! As she talked about the shake, I wondered about its dream component; how did Martha dream about me? In her dreams, was I a jailer, a friend, a lover?
I knew I could be none of those things to Martha, but then what roles were left? What does it mean to know someone as her physician, to receive her secret handshake? As I pondered these questions, my eye caught the clock. An important personage was downstairs, and I was late for his scheduled talk. I apologized to Martha, promised to return, and rode the elevator down to one of the hospital classrooms.
The basement conference room looked like any other. Rows of stacking chairs faced a raised podium behind which a man wearing a blue blazer stood like a prep school chapel speaker, except that instead of having an altar behind him, he had a screen on which to project his PowerPoint presentation. At the back of the room was an urn with coffee. I collected a burnt cup of coffee and a stale cookie. Lunch. I found a seat and tuned in to the speaker.
His slides were different from those of last month’s speaker, but they followed the same rhetorical script. Healthcare must be transformed. Old ways are dying. Disruptive innovations are afoot. Creative destruction is occurring. Revolution is at hand. The speakers always have a theory about how to fix medicine. That day the theory was efficiency itself. Efficiency in what? He never really said. Efficiency for its own sake, then. The speaker was an efficiency expert. He had studied the efficient delivery models of other industries. He told us that we have no patients, only customers. He said that we were not physicians but providers of healthcare services. He explained that we were a part of the healthcare industry, the largest industry in the country, not the medical profession, and we must adopt the efficient practices of other industries.
We get this kind of talk a lot. I never understand why the speakers are so certain, yet working so hard to convince us. If the revolution has arrived, why are you trying to convince us? Revolutions require no consent from the overthrown.
In fact, ever since I entered medical school at the University of North Carolina, I have been listening to these kinds of talks. At first, I found them exhilarating. When I enrolled at Chapel Hill, the talks were about how the human genome project would transform medicine. We were told that by the beginning of residency, we would be sequencing the genome of each patient. Residency began, and we were quietly told that sequencing had little clinical utility because knowing the base pairs of a person’s DNA is a bit like translating every third page of an instruction manual; the knowledge cannot be used to build something.
Halfway through medical school, the speakers starting talking about how stem cells would allow us to regrow injured organs in petri dishes. We were told that by the end of residency, we could grow new pancreases for diabetics. Residency ended, and we were told that while the cells could be grown in petri dishes, they were too unstable for humans.
At least the hopes shared in medical school were scientific. The speakers were physicians or scientists who believed that a line of research they were pursuing would soon improve human health. Everyone admired the speakers’ commitment to the scientific method, even if their evidence was preliminary.
Since leaving medical school, I have found that while the talks go on, the topics have changed. By the time I finished residency in 2009 and began attending basement talks at the hospital where I now work, the speakers were lecturing not on scientific breakthroughs but on changes in healthcare financing and delivery. Each was seeking consent for a purported revolution. Each offered a slogan (“In God We Trust. All others bring outcome data.”). Instead of pursuing new science, they wanted us to figure out how to implement the knowledge we had. Evidence-based medicine would synthesize the results of scientific studies. Comparative-effectiveness research would determine the best treatments. Electronic medical records would improve data gathering and prevent errors. The patient-centered medical home would reduce costly hospitalizations and increase patient compliance. Patient-centered outcomes research would measure the things that really mattered to patients. This decade of excited talk about revolution, creative destruction, and transformation culminated in legislation, such as the Affordable Care Act, which financed many of these initiatives.
After years of diligent attendance at the basement talks, I grew ambivalent about their ability to effect change, and the thought of sitting through another one often gives me a preemptive stomachache. Attending the basement talks now feels like visiting a restaurant that changes its menu too often. You are lured by the novelty, but you always leave unsatisfied because a chef needs more than a trendy recipe to make a decent meal. Just as food fads hurry through restaurant kitchens, our basement speakers are often promoting the latest fad favored by medical journals and government regulators. The speakers come around to hospitals and medical schools when the preliminary results are promising, but we never hear from them after their hopes are dashed in the follow-up trials.
So while I sat listening to the day’s basement speaker wax eloquent about efficiency, that day’s innovation du jour, my mind skipped from astronaut ice cream to fondue pots to molecular gastronomy. All these “innovations” have also had their moment, and, admittedly, they all had more appeal than my coffee-and-cookie lunch. Since I was determined to stick out the lecture, I looked for something to distract me from my hunger. There was not much to see in the basement. No art adorned the walls. No windows opened to the natural world. There were only bulletin boards. Most were covered with A3 and Pareto charts, but a few bore italicized quotations. One of these caught my eye. Attributed to Sir William Osler, it read, “The value of experience is not in seeing much, but in seeing wisely.”
Seeing much, huh? I do that every day. Every physician I know does that every day. And we still use the metaphor of Osler’s aphorism. Before I examine patients in the hospital, I tell the staff that I am “going to see my patients now.” The hospital always wants me to see more patients, because the more patients I see, the more bills I submit. Physicians have accepted this increased load because the more bills we submit, the more income we bring home. So hospitals are forever asking for physicians to evaluate more patients in the clinic, to perform more procedures in the operating room, and to examine more patients in the hospital. Seeing much is what we do.
In fact, seeing much is what we have been training physicians to do for the past hundred years. Medical education has favored “seeing much” through a high volume of experiences at least since the 1910 report on medical education written by Abraham Flexner. Flexner’s Report transformed American medicine by encouraging mastery through repeated experience. Before Flexner, most physicians trained through apprenticeships to practicing physicians in a particular community. Many medical schools were less rigorous than the high schools in their community, and Flexner’s Report characterized all but 6 of America’s 155 medical schools as inadequate.1 The leading exception was Osler’s own Johns Hopkins University School of Medicine. Although Osler himself disputed some of the characterizations of Johns Hopkins in the Report, he agreed with its central tenet—that the education of physicians should be rigorous and based on science. After Flexner, Hopkins and its Oslerian philosophy became the paradigm for all of medicine. Physicians now train at centralized research universities and teaching hospitals, where they work as part of shifting teams of physicians, before practicing in a particular community.
In the system spawned by Flexner, physicians leave whatever particular communities they may belong to so they can spend a decade or more developing specialized skills. Undergraduates are advised to attend the best medical school that accepts them, even if it is across the country in a place where the student knows no one. Residents and fellows are advised to train at the most prestigious program they can “match at,” even if it means uprooting a spouse from his or her employment. So instead of training with the general surgeon in his or her hometown, the student trains with the otolaryngologist at the nearest medical school—or, even better, with the renowned otolaryngologist at a distant research university. But once the student is there the faculty explains that otolaryngology is far too broad a field, so the student becomes a thyroid and parathyroid micro vascular otolaryngologist.
As their medical training extends, physicians leave their communities behind while narrowing their vision to an ever more specific part of the body, which they control through medical procedures. The student becomes a physician who follows the thyroid and parathyroid organs. If the patient has other concerns, he or she will need to see someone else. The lasting effects of Flexner’s Report include an explosion of medical knowledge and a series of technical advances, but also a fraying of the ties between physicians and communities. We belong to the hospitals in which we train and practice.
As physicians came, over the past century, to understand themselves as scientists, medical training changed first to focus on the volume of experiences and then to use population-based data to standardize their diagnoses and treatments. There is much good in such standardization. Who would want to return to a world where prescribed medicines had widely divergent amounts of active medications? Where each physician treated a particular condition based only on his or her personal experience? Where a patient stayed in the hospital simply for as long as the physician felt it necessary? But one can have too much of a good thing, and standardization can start to resemble monoculture, the cultivation of a single crop at the expense of life’s diversity.
When the speakers come to the hospital’s basement with proposals to renew medicine, they usually propose further standardizing physician performance and patient outcomes. The efficiency expert identified himself as an advocate of quality improvement, or QI. At the time, I was just learning about QI. I knew it was the most widely embraced proposal to renew medicine, endorsed by every major medical society, required by residency programs, and enacted by legislation. The speaker told us that quality improvement excels at preventing common mistakes. QI personnel develop behavioral “nudges” to promote hand washing among clinicians. They create checklists to prevent surgical complications. They turn evidence-based guidelines into order sets for physicians to follow.
All these practices have real merit, but they belong firmly to the category of seeing much. The goal is the best possible outcome for the most people, assessed by seeking signals from large datasets and developing universal findings before implementing them in particular communities. So when I discharge a patient from the hospital, I am judged on how closely my documentation meets national standards, not on whether a patient feels well or has been restored to health. As I practice, I often feel like a technician following a protocol, and I start to see patients in terms of outcome measures, another version of seeing much. In these arrangements, my authority as a physician derives from seeing much, from being able to employ a specialized knowledge.
I suppose this made sense when knowledge was difficult to come by, but specialized knowledge is now easily obtained. Computers excel at building knowledge databases beyond human capacity. If being a physician is simply a question of knowing much, then physicians will become increasingly unnecessary as databases grow in their scope and interpretative power. An entry-level smartphone can access more knowledge than any physician. To the extent that medicine is about specialized knowledge derived from large population samples, it can be turned into evidence-based medicine and decision-tree algorithms, and the physicians who practice such medicine can ultimately be replaced by databases. When those databases are eventually united with technical skills, providers with more specialized knowledge and more technical ability to consistently employ that knowledge will replace physicians.
Cue up the scary robot music.
The robots do not scare me, however, because whatever robots can do well, they should do. Robots can already sort, count, and dispense medication; they may soon compound and even select the appropriate medication for some conditions. Robots can assist pathologists and radiologists through visual-recognition software today, and they may soon automatically interpret many routine images. Robots can allow physicians to remotely examine patients today and may soon perform portions of the examination themselves. If physicians are simply people with specialized knowledge, then we ought to be replaced by robots. Someone will eventually train a robot to perform thyroid and parathyroid microvascular surgery.
And then what will be left for physicians to do? It may be the other half of Osler’s aphorism: See wisely.
. . .
The speaker finished talking. The lights came up, the universal sign that we were being released from our stiff seats. I walked upstairs, thinking of the speaker, of robots, of Osler, of Martha, and of food. I stopped by my office, dug a handful of almonds out of a desk drawer, and looked up Osler’s words. Osler was invoked often during my training—many medical schools have Osler Societies dedicated to medical humanism, and the coffee shop at my medical school was the Osler Café—but I never really learned much about him. I knew he was a famous physician of old, but I had read his aphorisms rather than his essays. His aphorisms always seemed aspirational—speaking to the best of being a physician and suggesting the way medicine ought to be. The yearning aphorisms, like the one on the conference room wall, suggested a way out of seeing much, a way out of cranking a queue of ill patients through the healthcare factory. We could follow wisdom’s call, we could see wisely, if we only followed Osler’s advice.
Searching online, I found the words in a commencement speech Osler gave in 1894, sixteen years before Flexner published his report, addressed to a graduating group of army surgeons. In between suggesting possible research topics based on the posts to which they were likely to be assigned, Osler named the army surgeons’ ability to move frequently as an advantage of their enlistment, saying, “Permanence of residence, good undoubtedly for the pocket, is not always best for wide mental vision in the physician.” He consoled the graduates that since they would move often, they would be “seeing much in many places.” He admitted that having no fixed home could isolate a physician, but if a surgeon grew weary of a remote outpost and felt it limited his learning, Osler counseled, “Comfort may be derived from a knowledge that some of the best work of the profession has come from men whose clinical field was limited but well-tilled. The important thing is to make the lesson of each case tell on your education. The value of experience is not in seeing much, but in seeing wisely. . . . In a ten or fifteen years’ service, travelling with seeing eyes and hearing ears, and carefully kept note-books, just think what a store-house of clinical material may be at the command of any one of you—material not only valuable in itself to the profession, but of infinite value to you personally in its acquisition, rendering you painstaking and accurate, and giving you, year by year, an increasing experience.”2 I was surprised. In my initial reading of the aphorism, I had assumed that Osler was sharply distinguishing between seeing wisely and seeing much. Reading his essay, I realized that Osler considered seeing much to be a requirement for seeing wisely. His counsel to the army surgeons was to leave particular communities in search of experience, of seeing much.
Although most of the address is taken up with general advice, toward the end it becomes clear that Osler had a particular example in mind. Osler closed by telling the graduating army surgeons about a nineteenth-century army surgeon named William Beaumont, a physician who truly saw much. Beaumont, like Osler himself, was a dedicated observer of the physiology of the body. From medical school lectures, I vaguely recalled that Beaumont had earned a place in the history of medicine because of his groundbreaking work on the process of digestion, which stemmed from a peculiar collaboration with a young Canadian named Alexis Bidagan dit St-Martin.
On June 6, 1822, St-Martin was visiting Mackinaw Island at the northern tip of Michigan’s lower peninsula. The island was home to the main trading post of John Jacob Astor’s American Fur Company, and St-Martin was a nineteen-year-old coureur de bois in the employ of the company. Given the island’s importance to the fur trade, it was protected by members of the United States Army stationed at Fort Michilimackinac. One day St-Martin was shot in the stomach, and Beaumont, the fort’s resident physician, was called in to care for him. To Beaumont’s surprise, St-Martin’s injury had not proved fatal. Instead, his broken part had healed itself in an odd way: St-Martin’s stomach formed a fistula, a communicating passage between his stomach and his abdominal wall, at the site of the wound. Beaumont tried to close the fistula but failed.3
As Beaumont gazed into St-Martin’s open fistula, he saw an opportunity; by means of this anomaly he could study how food is digested in the stomach. Beaumont initially studied the operations of St-Martin’s fistula at Fort Michilimackinac. When the army eventually decided it could no longer subsidize Beaumont’s experiment and St-Martin’s recovery, Beaumont moved St-Martin into his own home. There he kept St-Martin immobile and starved him for days at a time in order to conduct experiments on digestion. Once St-Martin’s stomach was completely empty, Beaumont would insert foodstuffs—a partial list from Beaumont’s notebook includes animal spinal marrow, apple dumplings, fresh beef suet, Irish potatoes, mellow peaches, old strong cheese, and solid hog’s bone—through a glass funnel placed inside the fistula and remove the foodstuffs at varying intervals to assess how they had been altered by their time in St-Martin’s stomach. Eventually, Beaumont came to an understanding of the mechanisms of digestion, earned international renown, and inaugurated a physician-patient relationship that seems like a perverse model for contemporary medicine.
Beaumont at times succored St-Martin, nursing him to health, and at other times starved him and exploited him, paying the illiterate St-Martin to participate in experiments but never sharing the book royalties and speaking fees that were generated through his work. Hampered by his physical disability and alcoholism, St-Martin struggled throughout his life to find employment other than as a research subject for Beaumont. On several occasions, St-Martin fled from Beaumont, and the physician gave chase to the patient of whom he had seen so much but wanted to see still more.
Osler praised Beaumont’s efforts at the end of his speech, telling the graduating army surgeons, “William Beaumont is indeed a bright example in the annals of the Army Medical Department, and there is no name on its roll more deserving to live in the memory of the profession of this country.” Osler praised the “persistence with which for eight years Beaumont pursued the subject, except during two intervals when St. Martin escaped to his relatives in Lower Canada. . . . The determination to sift the question thoroughly, to keep at it persistently until the truth was reached, is shown in every one of the 238 experiments that he has recorded. The opportunity presented itself, the observer had the necessary mental equipment and the needed store of endurance to carry to a successful termination a long and laborious research.”4 Osler praised Beaumont for his persistence and endurance—his 238 experiments—without mentioning the persistence and endurance of St-Martin. He never acknowledged why St-Martin might have fled.
Osler’s fascination with Beaumont was no commencement day lark. He published a separate essay on Beaumont’s experiments, and his biographers say that when Osler taught students about gastric physiology, he regaled them with tales of St-Martin, whom Osler called “old fistulous Alexis, the old sinner.”5 He routinely asked his students where St-Martin’s stomach should reside when its owner, the now aged St-Martin, died. Although St-Martin outlived Beaumont, Osler took up Beaumont’s cause, saying it would be a shame for St-Martin’s stomach to decompose in a rural cemetery. St-Martin’s stomach belonged, Osler insisted, in the United States Army Museum in Washington, D.C.
This was also not idle chatter between a teacher and his students. Osler maintained a correspondence with the local physician in the town where St-Martin lived out his last days, seeking news of St-Martin’s health. Osler thought often of St-Martin’s stomach and desired to perform an autopsy on the elderly subject, but St-Martin and his family concluded that they wanted no further role in medical research. When St-Martin died, on June 20, 1888, Osler received a telegram telling him that he would not be allowed to perform the autopsy. St-Martin’s family refused all offers of money for his fistulous stomach, his famous part. Instead, they buried St-Martin’s body below two feet of stones and six feet of dirt to ward off grave robbers and physicians, groups that were often one and the same at that time. Neighbors kept watch over the grave armed with muskets to give St-Martin the peaceful rest he never received in life.
Is that what it means to see much? To be so enamored of learning how the parts of the body work that you hound a fellow human beyond the grave? Apparently so, because every few years a medical journal will publish an article commemorating the store of knowledge generated from old fistulous Alexis.6
Through such articles Osler remains the most celebrated physician in recent memory, acclaimed as the father of contemporary medicine. Even though Osler never developed a novel treatment or cured an illness, his words still adorn hospital walls because of his renown as a master teacher. He gave addresses that are still read by aspiring and practicing physicians. He was the first medical educator to take students out of lecture halls and to the bedsides of ill patients. He developed the first residency program. He was a founding physician of the Johns Hopkins University School of Medicine, the first truly contemporary medical school. He perfected the contemporary medical teaching service, in which a medical student, intern, junior resident, chief resident, and fellow follow an attending physician like climbers following a leader as they ascend a ladder, each examining the team’s patient and sharing responsibility for the patient’s care. Osler’s ladder was the model praised in Flexner’s Report as the way to reform medicine, so, in a way, it was fitting that it was Osler’s words that distracted me from the basement speaker’s own talk of reform. After all, that basement room was called the Osler Classroom.
. . .
A contemporary hospital can seem like an expansive Osler Classroom. Osler remains the kind of physician the basement speakers desire to be. He is widely remembered as a tireless teacher, a perceptive physician, a heartfelt humanist. Osler is credited with achieving the grand synthesis: a medicine that is at once rigorously scientific and deeply humane. Story after story about Osler credits him with being a physician who cared for his patients and who recognized the humanity of each one; in portraits, he is often portrayed, without irony, with the attributes of a saint. Osler’s hands bore prosector’s warts (what dermatologists call tuberculosis verrucosa cutis)—tubercular warts from the autopsies he conducted—physical marks of suffering for his work that are analogues of a saint’s stigmata.7
Is this what physicians are supposed to be? Scientist-saints? Martyrs for medicine? When I read about Alexis St-Martin, Beaumont and Osler did not strike me as saints or martyrs. At best, they sounded like benefactors, but the relationship could more accurately be described as that between scientist and subject. When we consider the lengths that these physicians went to access the most intimate parts of the man’s body, we might even see them in a more sinister light. Social mores change, but I doubt it was ever common to post armed guards around the bodies of elderly, illiterate, disabled Canadian fur traders. In fact, historians recently learned that Osler developed a way to conduct covert autopsies when a patient or a family would not consent. By making small incisions behind the scrotum or within the vaginal vault of a deceased person, Osler could remove organs from the abdomen and thorax of deceased patients for his collection of diseased specimens, and then sew up the body for burial without anyone knowing.8 Historians also estimate that during Osler’s tenure about half the cadavers used by students at John Hopkins were obtained illegally.9 The muskets of St-Martin’s family appear to have been necessary.
In my medical specialty, psychiatry, questions of exploitation remain relevant. My patient Martha, for example, could read, but she too was elderly and disabled. She would have been easy to exploit. She lived on the margins of society. She was often confused. She was ill more often than she was well. She had no parents, spouse, or children who would mourn her. She had only her sister.
And she had me. What was the nature of our relationship? Was I her friend? Her savior? Was I the scientist studying her body the way Beaumont studied St-Martin’s body? Was she in some way my subject? Who are a physician and a patient when they meet each other? These are the questions to ask.
Six months after listening to the basement speaker deliver his talk about efficiency, and still thinking about Osler’s aphorism, I received a call from Martha’s sister. Through tears, she said, “Martha died last week. Pneumonia. Before she passed, she wanted me to tell you good-bye.” I thanked her for the call, talked a few minutes more, hung up the phone, and cried at my desk.
No more Martha. No more dream shakes.
She was no longer around for me to ask who we really are to each other when we meet as physician and patient.
But she left me with memories and a question: What would it mean for a physician to see a person wisely? I had looked up Osler’s words because I thought they pointed the way to a practice of medicine that was both humanistic and scientific, a way to explain a day that included caring for Martha and listening to the basement speaker. Osler’s words had led me to Beaumont’s work and St-Martin’s guarded grave, so Osler’s answers unsettled me—even our most celebrated physician was obsessed with parts and money—and I knew I would have to look elsewhere. I did not want Martha’s family guarding her grave against my exploration. So I wondered whether Martha’s dream shake could, alongside Osler’s aphorism, give me a clue.
When I became a physician, I learned to see people—friends, neighbors, and strangers alike—as patients. I could see things in them that I could not see before. There were also aspects I could no longer see after I saw people as patients. The most insightful historian of contemporary medicine, Michel Foucault, wrote that medicine was transformed not by creative discoveries, innovative techniques, or the just distribution of resources but when physicians changed how they saw other people.10 Basement speakers did not discuss these transformations: they acted as if medicine would be transformed by creative discoveries (like Beaumont’s deduction of digestion) or innovative techniques or the just distribution of resources. When we talk about healthcare reform, no one talks about vision or perception. Instead they talk about the need for better treatments, better delivery systems, better funding mechanisms.
Healthcare reform is often described as a single event, but in the hospital we experience it as a series of competing initiatives. They overlap in partially coordinated rollouts and launch parties. At one, a policy expert decides that a group of physicians should embrace the patient-centered medical home and hire primary care providers because grants are available to start the program. At the next, a business consultant decides that the number of orthopedists should be doubled to maximize revenue and starts replacing the primary care practitioners with orthopedists. Then a tech guru decides that electronic medical records will increase billing and reduce errors, so he or she persuades the hospital to stop hiring orthopedists or primary care practitioners and spend its capital on technology consults. The changes can be dizzying.
I lack the training to evaluate all these proposals. To do that job well requires decades of training in economics, medicine, public policy, and more. I can offer a participant’s view of these changes, of what it is like to live through the reforms celebrated by basement speakers. But my belief is that the best hope for medicine lies in physicians seeing patients as particular, unique individuals—while following, in the words of the Hippocratic Oath, the finest traditions of our calling.
Physicians like me need wise vision to renew medicine. But who can teach us? The basement speaker distrusted wisdom, and now I distrusted Osler. Martha was the only person I had trusted that day, and she had joined the company of the dead. I decided to revisit my own training to figure out how I had arrived at this place. What lessons in seeing had I already received, and what had they done to me?