Narrative
He had always wanted to be a physician. It took him thirty years, beginning in ‘dust bowl’ poverty. The youngest of three children in a homesteading family on the southwestern prairie, his determination guided him through eight grades at a one-room school and on to the state university. He did poorly his first college year -- too far behind in learning, too many hours working to pay his way. Then the war . . . and the draft. He took advantage of every educational opportunity military training offered. Shipped to England, he co-piloted a B-17 crew on bombing runs over Germany. Shot down and missing in action, he struggled to survive in a POW camp. He was below a hundred pounds and fighting hepatitis when Patton’s Seventh Army liberated the camp.
Once reunited with his family and sufficiently mended, he returned to the state university, graduating with a medical degree in 1951. After finishing post-graduate rotations in obstetrics, cancer surgery, endocrinology, and gynecology, he practiced in a small town for a year as the only physician trained in obstetrics and then moved to join two other physicians in a practice that would be his professional home for the next forty years.
Definitions
We humans are clearly bent on being together -- usually by choice, at times by necessity. And yet the result of our being together seems ironically to dehumanize those we are near. Whether spouse, child, friend, colleague, or stranger, . . . whether patient or physician -- it is a profound and difficult achievement to be with another person and do no harm, but instead to show respect and to justify trust. These terms -- do no harm, respect, trust -- take us to the core of the patient-physician relationship our young physician envisioned with his first patient in 1951 and his last patient in 1991.
Harm means to injure, to wound, to humiliate. Harm has already begun where there is disrespect and erosion of trust. Harm results when power is misused by one or the other in a relationship. Power -- an ever-present and shifting reality when patients and physicians are together -- ranges in nuance from impact, influence, creation, strength across a spectrum to force, control, abuse, exploitation, destruction.
For a concrete image of respect, just break the word down into its Latin parts -- re + specere. To respect is to look at closely again and again, to listen carefully again and again. And so the premium assigned to such traits as patience, altruistic interest, confidentiality, modesty, attention to subtle disclosures.
For a vivid image of trust, consider a rather common scene back in the 1950s. A workman who is assigned to repair phone or electric lines straps on spikes to the inside of his work boots. He ‘walks’ up the pole, digging in the spikes and slinging upward the thick security belt he has looped around the utility pole and hooked to his tool belt. Near the top of the pole, he leans back from the pole. Hands free, he begins to repair the lines. Leaning back from the pole and depending on the security belt – that is trust.
Concerns about health bring patients and physicians together. There is a certain pragmatism to the relationship. What is the desired ‘end’ and how do we best get there? That is the stuff of ethics -- i.e., figuring out what ought to be done (if anything), all things considered. The patient and the physician both have to reach the minimal thresholds of mutual respect and trust to proceed toward the desired ‘end’ without injuring and humiliating each other. Some considerations on their minds encourage respect and trust. Other considerations permit or force patients and physicians to drift apart, to remain or become strangers.
Commentary
1951. The young physician we introduced a few minutes ago, began to see his patients in 1951. He had become a physician. A childhood dream, tempered by severe life experiences, had become a reality. Granted, he had just recently been adding his share of stories to the lore of student faux pas. But that young physician with his first patient in 1951 had learned to think, to talk, to dress like a physician. He had been socialized into the cloistered fraternity of medicine. He entered medical education seeing as the patient would see. By the end, he had learned the physician’s view of things. Seeing as a physician while not being blind to the patient point of view seemed possible then. He had embraced the proposition, as articulated in a 1932 AMA Commission Report, that the essence of being a physician is “the capacity to observe, to reason, to compare his observations and reasoning with those of others, and the capacity to place himself in his patient’s place -- in a word, compassion”.
1951 was an exciting time to enter the practice of obstetrics and gynecology. Obstetrics at the turn of the century had attracted few physicians. General surgeons did the few cesarean sections. A 1932 Presidential Conference on Child Health report looked back at the turn-of-the-century obstetrician as occupying “a menial place, entirely unenviable, in the medical school and the hospital, with scant respect from the public at large”. The majority of births occurred at home. For every 10,000 live births, 80 mothers died. As recently as 1920, American obstetrics had been called a national disgrace. Then a year later, Congress passed the Act to Promote the Welfare of Maternity and Infancy, requiring states to establish centers for prenatal and infant care. By 1936 -- the year of the Social Security Act -- all states were complying with the 1921 guidelines. 1937 saw the formation of Maternal Mortality boards in state medical societies. With the outbreak of war, Congress enacted the Emergency Maternity and Infant Care Act to cover the wives and children of soldiers. By the time the wartime emergency had passed, the federal government’s role in the promotion of maternal health had taken root.
In 1921 there were just eleven chartered obstetric societies. The 1928 AMA directory listed fewer than ten residency programs for obstetrics and gynecology. Only two generations earlier, advocates of vaginal examinations had to refute prophets of moral doom. In time, a series of breakthroughs -- beginning with the first reported cure of cervical carcinoma in 1900 -- brought definition to gynecology, then a branch of general surgery. A corps of medical crusaders established in 1930 the American Board of Obstetrics and Gynecology, the certifying body for the merging specialties. The ranks of obstetrician-gynecologists grew rapidly, as evidenced by the proliferation of chartered obstetric and gynecologic societies.
By 1944 two out of three births occurred in hospitals. In 1945 the National Federation of Obstetric and Gynecologic Societies was organized to consolidate the specialty, in part to stall federal control of maternal health care. The Federation was reorganized in 1951 into the American Academy (College) of Obstetrics and Gynecology. Members had to be physicians who had confined their practice to either obstetrics or gynecology for five years and who had the endorsement of their local colleagues. Within two months, the Academy (College) had 2000 applicants. Being a Fellow meant:
A 1954 ‘After Hours’ column in the American Journal of Obstetrics and Gynecology celebrated the ‘Cinderella Story’ of the specialty. That same year, ACOG’s president proclaimed, “We have come of age”. Yet another inaugural address described the specialty as “a rising sun”. And why not? For every 10,000 live births in 1920, 80 mothers died. For every 10,000 live births in 1950, 7 mothers died. “She is devoted to her obstetrician” was an observation heard often and for very good reasons. But this devotion was also fraught with danger as patient respect could escalate to awe, as patient trust could be blind, as physician confidence could override caution. Still, we would be guilty of the classic historians’ fallacy if we held patients and physicians in or around 1951 accountable for failing to see the harmful consequences that, with hindsight, look so obvious and inevitable.
He had always wanted to be a physician. It took him thirty years, beginning in ‘dust bowl’ poverty. The youngest of three children in a homesteading family on the southwestern prairie, his determination guided him through eight grades at a one-room school and on to the state university. He did poorly his first college year -- too far behind in learning, too many hours working to pay his way. Then the war . . . and the draft. He took advantage of every educational opportunity military training offered. Shipped to England, he co-piloted a B-17 crew on bombing runs over Germany. Shot down and missing in action, he struggled to survive in a POW camp. He was below a hundred pounds and fighting hepatitis when Patton’s Seventh Army liberated the camp.
Once reunited with his family and sufficiently mended, he returned to the state university, graduating with a medical degree in 1951. After finishing post-graduate rotations in obstetrics, cancer surgery, endocrinology, and gynecology, he practiced in a small town for a year as the only physician trained in obstetrics and then moved to join two other physicians in a practice that would be his professional home for the next forty years.
Definitions
We humans are clearly bent on being together -- usually by choice, at times by necessity. And yet the result of our being together seems ironically to dehumanize those we are near. Whether spouse, child, friend, colleague, or stranger, . . . whether patient or physician -- it is a profound and difficult achievement to be with another person and do no harm, but instead to show respect and to justify trust. These terms -- do no harm, respect, trust -- take us to the core of the patient-physician relationship our young physician envisioned with his first patient in 1951 and his last patient in 1991.
Harm means to injure, to wound, to humiliate. Harm has already begun where there is disrespect and erosion of trust. Harm results when power is misused by one or the other in a relationship. Power -- an ever-present and shifting reality when patients and physicians are together -- ranges in nuance from impact, influence, creation, strength across a spectrum to force, control, abuse, exploitation, destruction.
For a concrete image of respect, just break the word down into its Latin parts -- re + specere. To respect is to look at closely again and again, to listen carefully again and again. And so the premium assigned to such traits as patience, altruistic interest, confidentiality, modesty, attention to subtle disclosures.
For a vivid image of trust, consider a rather common scene back in the 1950s. A workman who is assigned to repair phone or electric lines straps on spikes to the inside of his work boots. He ‘walks’ up the pole, digging in the spikes and slinging upward the thick security belt he has looped around the utility pole and hooked to his tool belt. Near the top of the pole, he leans back from the pole. Hands free, he begins to repair the lines. Leaning back from the pole and depending on the security belt – that is trust.
Concerns about health bring patients and physicians together. There is a certain pragmatism to the relationship. What is the desired ‘end’ and how do we best get there? That is the stuff of ethics -- i.e., figuring out what ought to be done (if anything), all things considered. The patient and the physician both have to reach the minimal thresholds of mutual respect and trust to proceed toward the desired ‘end’ without injuring and humiliating each other. Some considerations on their minds encourage respect and trust. Other considerations permit or force patients and physicians to drift apart, to remain or become strangers.
Commentary
1951. The young physician we introduced a few minutes ago, began to see his patients in 1951. He had become a physician. A childhood dream, tempered by severe life experiences, had become a reality. Granted, he had just recently been adding his share of stories to the lore of student faux pas. But that young physician with his first patient in 1951 had learned to think, to talk, to dress like a physician. He had been socialized into the cloistered fraternity of medicine. He entered medical education seeing as the patient would see. By the end, he had learned the physician’s view of things. Seeing as a physician while not being blind to the patient point of view seemed possible then. He had embraced the proposition, as articulated in a 1932 AMA Commission Report, that the essence of being a physician is “the capacity to observe, to reason, to compare his observations and reasoning with those of others, and the capacity to place himself in his patient’s place -- in a word, compassion”.
1951 was an exciting time to enter the practice of obstetrics and gynecology. Obstetrics at the turn of the century had attracted few physicians. General surgeons did the few cesarean sections. A 1932 Presidential Conference on Child Health report looked back at the turn-of-the-century obstetrician as occupying “a menial place, entirely unenviable, in the medical school and the hospital, with scant respect from the public at large”. The majority of births occurred at home. For every 10,000 live births, 80 mothers died. As recently as 1920, American obstetrics had been called a national disgrace. Then a year later, Congress passed the Act to Promote the Welfare of Maternity and Infancy, requiring states to establish centers for prenatal and infant care. By 1936 -- the year of the Social Security Act -- all states were complying with the 1921 guidelines. 1937 saw the formation of Maternal Mortality boards in state medical societies. With the outbreak of war, Congress enacted the Emergency Maternity and Infant Care Act to cover the wives and children of soldiers. By the time the wartime emergency had passed, the federal government’s role in the promotion of maternal health had taken root.
In 1921 there were just eleven chartered obstetric societies. The 1928 AMA directory listed fewer than ten residency programs for obstetrics and gynecology. Only two generations earlier, advocates of vaginal examinations had to refute prophets of moral doom. In time, a series of breakthroughs -- beginning with the first reported cure of cervical carcinoma in 1900 -- brought definition to gynecology, then a branch of general surgery. A corps of medical crusaders established in 1930 the American Board of Obstetrics and Gynecology, the certifying body for the merging specialties. The ranks of obstetrician-gynecologists grew rapidly, as evidenced by the proliferation of chartered obstetric and gynecologic societies.
By 1944 two out of three births occurred in hospitals. In 1945 the National Federation of Obstetric and Gynecologic Societies was organized to consolidate the specialty, in part to stall federal control of maternal health care. The Federation was reorganized in 1951 into the American Academy (College) of Obstetrics and Gynecology. Members had to be physicians who had confined their practice to either obstetrics or gynecology for five years and who had the endorsement of their local colleagues. Within two months, the Academy (College) had 2000 applicants. Being a Fellow meant:
To establish and maintain the highest possible standards for obstetric and gynecologic education in medical schools and hospitals, in obstetric and gynecologic practice, and in research; to perpetuate the history and best traditions of obstetric and gynecologic practice and ethics; to maintain the dignity and efficiency of obstetric and gynecologic practice in its relationship to public welfare; to promote publications and encourage contributions to medical and scientific literature pertaining to obstetrics and gynecology.And so, our young physician began his practice at a time when patients trusted their physicians’ decisions, when examinations depended on observation and touch, when case reports in the medical literature provided context for clinical judgments, when lawyers and economists remained far from the bedside, when ethics had to do with the sort of person you were, when parents would bring a $125 payment for a delivery done eight years before.
A 1954 ‘After Hours’ column in the American Journal of Obstetrics and Gynecology celebrated the ‘Cinderella Story’ of the specialty. That same year, ACOG’s president proclaimed, “We have come of age”. Yet another inaugural address described the specialty as “a rising sun”. And why not? For every 10,000 live births in 1920, 80 mothers died. For every 10,000 live births in 1950, 7 mothers died. “She is devoted to her obstetrician” was an observation heard often and for very good reasons. But this devotion was also fraught with danger as patient respect could escalate to awe, as patient trust could be blind, as physician confidence could override caution. Still, we would be guilty of the classic historians’ fallacy if we held patients and physicians in or around 1951 accountable for failing to see the harmful consequences that, with hindsight, look so obvious and inevitable.
