Defined Elsewhere

Any doubts I may once have had about the truth of that statement dissipated as I read a recent article in one of my favorite publications, The American Scholar. The words of William Cronon, the Frederick Jackson Turner Professor of History, Geography and Environmental Studies at the University of Wisconsin, began to resonate as I gained clarity about the best of what physicians can and should become.

Just read his introduction: "Liberal education is built on these values; it aspires to nurture the growth of human talent in the service of human freedom." Cronon amplifies his definition. He points out that it is important to avoid making lists to define this education leading to human freedom. Lists, he says, tend to take the form of course requirements or, perhaps worse, the banalities of a committee report.

"One problem," says Cronon, "is that it is much easier to itemize the requirements of a curriculum than to describe the qualities of the human beings we would like that curriculum to produce." He seems to know that whether the cart is in front of or behind the horse, designing the cart properly is paramount.

Perhaps with some irony, Cronon produces a list of his own by asking the question: "How does one recognize liberally educated people?" I believe that his list, by all measures, is a good one. Cronon's points about how to recognize liberally educated people are in italics, followed by my comments on how these relate to physicians.

They listen and they hear. Physicians must know how to pay attention to patients as well as to the world around them. This is hard but essential work.

They read and they understand. The essence here is that not only must physicians dutifully peruse the New England Journal of Medicine and various subspecialty journals, as well
as The New York Times, they must also recognize useful and important material on the World Wide Web, in Vogue and even in The National Enquirer. The mandate is to understand nature - the differences between finches and jays - appreciate varieties of music and discern fine craftsmanship as well as fine art.

They can talk with anyone. Heterogeneity is a fundamental characteristic of patients who come into our offices. Physicians must know how to gain the confidence of all people - drug addicts, politicians, librarians and even other physicians. Physicians communicate best when they are genuinely interested in what their patients have to say.

They can solve a wide variety of puzzles and problems. This is what doctors do all day. We must have the ability to look at a complicated reality, break it into pieces, reassemble it in the context of medical science and make recommendations that lead to cure or alleviation of suffering.

They respect rigor not so much for its own sake but as a way of seeking truth. Cronon says, "Truly educated people love learning, but they love wisdom more." The rigorous knowledge of a subspecialty field in medicine is an important achievement of fellowship training, for example, but it is worthless, sometimes dangerous, unless used in the context that each patient brings to the examining room.

They practice humility, tolerance and self-criticism. Cronon suggests that "this is another way of saying that they can understand the power of other people's dreams and nightmares as well as their own. They have the intellectual range and emotional generosity to step outside their own experiences and prejudices, thereby opening themselves to perspectives different from their own." The physician must always hold death and disease in awe, not to do so invites sorrow.

They nurture and empower the people around them. "Nothing is more important in tempering the exercise of power and shaping right action than the recognition that no one ever acts alone," Cronon writes. This obviously applies to the surgeon in the operating room but, until recently, probably less to the internist in the office. Now, however, the internist and other primary care physicians know that they are part of networks, and the patients they serve are not only individuals but are now also members of subpopulations that include many people whose care must be viewed cohesively. Successful encounters with the health care system are dependent on many contributors: receptionists, nurses, pharmacists, physical therapists, dietitians, floor sweepers, insurance companies - as well as doctors. Nevertheless, it is still up to physicians to make the systems containing so many different people work effectively.

And finally. . .

They connect. Of this critical last item on the list, William Cronon says, "More than anything else, being an educated person means being able to see connections that allow one to make sense of the world and act within it in creative ways. Every one of the qualities I have described here - listening, reading, talking, writing, problem solving, truth seeking, viewing through other people's eyes, leading, working in a community - is finally about connecting."

Perhaps it is this ability to connect these characteristics that gives physicians the enthusiasm to go on each day, to confront discouragement, failure and even death, and still avoid burnout or depression. Perhaps mixing these characteristics inspires a patient's strength to heal, and if that is impossible, at least we have tried.

President's Column

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