Medicine as Vocation: An Interview with Dr. Abraham Nussbaum
Author of: The Finest Traditions of My Calling
The evolution of medicine away from individual patient-centered care and towards a more efficient, population-based approach has had large repercussions on the quality and depth of care delivered to the ill. As healthcare reforms in the United States continue to be made, the patient-physician relationship is being strained as the practice of medical care moves physicians away from seeing patients for more than their physical ailments. Dr. Abraham Nussbaum, director of adult inpatient psychiatry at Denver Health, thoughtfully examines this trend in The Finest Traditions of My Calling. Utilizing neglected history of medicine and personal stories, he offers insight on how reforms are harming the practice of medicine and provides alternate ways to conceptualize a physician’s role in healthcare. Dr. Nussbaum uses the history and incorporation of religion and medicine as a common thread throughout his book, challenging health care reforms that encourage physicians to see themselves as mere scientists whose role is to fix broken physical bodies rather than as teachers, servants, and gardeners who must see their practice as one that cultivates health.
In the following interview, Dr. Nussbaum shares his perspective on how the incorporation of religion into the medical practice provides a way for physicians to become more effective in working towards healing for their patients.
1. What was your inspiration in writing The Finest Traditions of My Calling?
My inspiration came from a lifetime of reading. To be honest, I started with the classics—stacks of secondhand Marvel comics—and only later advanced to less colorful material. I am the oldest of five children, and we lived in a bustle, so I suppose I read to be alone with other people’s thoughts. In our busied house, I found that reading was the best way to marshal a moment of silence. In time, I realized that reading was forming me and I became worried that I would miss the books I needed. I suppose I still have that worry. Even now, I am usually reading four or five books at any time, trying to keep up with my betters. I know both that I can never keep up and that no book will ever mean as much to me as the books which I read when I was most malleable. So the honest answer is that while this book relies upon many of the books I read while writing, I owe its narrative structure to Walker Percy’s The Moviegoer, its critique to Foucault’s Birth of the Clinic, and its resolution to Basil’s Long Rule. I alone bear responsibility for the fumbling prose.
2. Can you tell us more about what it was like to write this book? What parts did you find easy to write and what were the most difficult sections for you to write? Why?
I have never taken a writing course, so I had to learn on the job. At times, it felt like finding the loose ends of a long-knotted rope, untying them, and then pulling them taut. After years of writing academic papers, my ideas were folded in upon themselves. To open them up, I had to read differently, observing how the writers I admired used character and story to display their arguments and their evidence. The chapters which began as academic papers proved the most difficult to rewrite, because you cannot just add a character and a story to a knotted argument, you have to plait the character and story around the argument. So I had to develop a narrative voice, a version of myself that could be a character in the narrative, and think over my own experiences in search of stories which would illustrate the themes of each chapter. Inevitably, the stories altered those themes for the better. A true story has its own argument, and I had to find it through writing. In the end, I came closest to this kind of writing in the epilogue.
3. What are some of the benefits of understanding the roots of medicine in religion rather than seeing medicine grounded in science?
Medicine is a cultural phenomenon—one of the activities which distinguishes us from other animals—and always displays our beliefs and commitments. So it is no surprise that contemporary medicine favors the technological and industrial encounter. We attribute that to science, but those values are our own, not values intrinsic to science. Medicine has certainly advanced by engaging science, but it has never been science itself, and so the roots of medicine are cultural. Much of what we assume about contemporary medicine has its roots in aspect of human culture that we, today, call religious. So I work at a public hospital, where people can receive care irrespective of their ability to pay. The reason that hospitals exist is not rooted in science—care for all is not a scientific idea—but in a religious impulse to care for the indigent ill. It seems to me that commitment to the indigent ill has wavered in contemporary medicine, and to do my small part in rekindling it a bit, I returned to its initial light.
4. You use William Osler’s idea of the importance of “seeing much” throughout your book with regards to seeing patients for more than broken parts or simply medical diagnoses. What hinders physicians from “seeing much,” even in the realm of psychiatry where there is inherent need to understand more than just the physical body?
Even physicians who rarely read know at least one or two of Osler’s aphorisms, perhaps “The good physician treats the disease; the great physician treats the patient who has the disease” or “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” Osler had a great sense of language and metaphor. (I suspect he learned some it from his father, Featherstone Osler, a sailor who became an itinerant minister; Osler’s best essays read like sermons.) I initially knew Osler through his aphorisms and received one of them—“The value of experience is not in seeing much, but in seeing wisely”—as a sharp distinction in favor of wisdom, of learning to see the people we met as patients truly and well. As so often happens, when I looked up the actual essay from which this aphorism comes, I was surprised that Osler believes that you have to see much in order to see wisely. And what he means by “seeing much” disturbed me, because it requires a kind of control over patients that seems abusive today; our heroes are weirder and more complicated than we imagine.
5. How does being attentive to patient’s religion or spirituality help physicians “see much”?
Attentive is a great term, and it makes me think of one of my favorite medical adverbs: attending, a terrific description for a learned physician. To attend is to apply your labors, your efforts, outward from yourself. Medically, it means to stretch out towards the person before you. Doing so that means you are interested in that person, and to be interested in a person necessarily means to ask after the practices and beliefs which provide their meaning and identity. It means that you ask about the people with whom they live and with whom they make meaning. You cannot know a person you meet as a patient without being attentive to a person’s religion or spirituality.
6. You often mention that the structure of medical practice and medical institutions tends to demand physicians to become more focused on efficiency in diagnosing medical problems and in turn discourages them from caring for patients’ whole bodies. Is the re-incorporation of religion into medicine possible in the current system of medical care and pluralistic society in the United States?
A friend of mine, Jeff Bishop, has written about the “dose effect” model of the medical humanities, the idea that you could reform contemporary medicine by administering a particular dose of humanity to the whole enterprise. Those kinds of arguments seem disingenuous to me in the same way that what passes for healthcare reform seems similarly disingenuous. Shifting from a fee for service model to a value-based model does not transform the system, it simply means clinicians are no longer paid for their labor, they are paid for their outcomes. That changes the mechanism of our exchange economy, but it still imagines the medical encounter as a transactional encounter. To me, what we need is the renewal of medicine, where medicine is based on relationships instead of transactions. We do not need a dose of humanity or spirituality in medicine, we need a reorientation, a renewal, around relationships.
7. You use the metaphor by Hildegard and Sweet of health care workers being “gardeners of health.” How does being attentive to patient’s religion or spirituality embody the idea of being “gardeners”?
Much of what goes on in contemporary medicine feels analogous to contemporary agriculture: just as we prioritize crop yields in agriculture, we prioritize population outcomes in medicine. Our current version of healthcare reform is essentially a big agribusiness version of medicine. Which strikes me as a peculiar, because after going through the big agribusiness model in food, people and communities have become interested in models which are local, sustainable, and particular. Where I live there is a great deal of interest in gardening instead of farming, growing some of our own food instead of relying upon agribusiness. Reflecting upon this and reading Victoria Sweet’s terrific book God’s Hotel, I started thinking about what it would mean to practice medicine more like a gardener than like a commercial farmer. Sweet believes it would mean attending to a person’s ability to heal herself, to considering the place in which she lives, and tinkering with it, in pursuit of health. She arrived at the vision only after engaging with the writings of Hildegard of Bingen, another reminder that physicians need to return to our original lights if we truly want to renew the practice of medicine.
Interview by: Sarah Philbrick, BA