Observations Ethics Man

Wonder in medicine

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4976 (Published 25 November 2009) Cite this as: BMJ 2009;339:b4976
  1. Daniel K Sokol, honorary senior lecturer in medical ethics, Imperial College London
  1. daniel.sokol{at}talk21.com

    There is something amiss if medical professionals no longer have the capacity to be astonished by their work

    The lectures we attend, like the articles we read, seldom withstand the ravages of memory. Two lectures, however, are etched in my mind. The first was delivered to all of three students by a professor of romance languages. Its unpromising topic was morphology (which in linguistics concerns the structure of words). The second, by a member of the Inner Magic Circle of London, was on showmanship. He revealed the secrets of turning ordinary tricks into full blown miracles. More than mastery of their subject, the two lecturers had the panache of Cyrano. They also exuded a profound sense of wonder—a wonder at the magic of language and the beauty of a visual illusion.

    The Greeks called this sense of wonder or bewilderment “thauma.” Plato believed it “the mark of the philosopher,” and his student Aristotle considered it the precursor to wisdom, for it forms the starting point of philosophy. Leafing through the patients’ notes of the neurosurgeon Harvey Cushing, I found this sense of wonder to leap out from his writings, photographs, and hand drawn sketches.1 He viewed the pituitary gland and its disorders with awe. Another US surgeon, Sherwin Nuland, admits in his book on the history of human organs that his “fascination with medicine has been renewed over and over again by challenging and exhilarating contacts with patients, disease, and the response of the organs of the body.”2

    Clinicians and medical ethicists are regularly confronted with odd or extraordinary situations, and there is something amiss if even as experienced professionals we are no longer astonished by these situations. Such indifference may indicate a lack of humility, for to experience wonder we must be attuned to our limits and ignorance. So vast is the field of medicine that the most accomplished physician will be familiar with little more than a speck. To paraphrase Cushing, the kaleidoscope of medicine is constantly turning.3 No individual can singlehandedly master the subject.

    Much of our work, it is true, is not wonder-full. Filling forms, dictating letters in the clinic, or marking hundreds of exam scripts is underwhelming. Yet, even in the humdrum, glimpses can be caught. Reading a student’s essay, I was looking for a tree and a sturdy piece of rope when I stumbled on this sentence: “All humans should be treated with equal prejudice.” Once my laughter subsided, the phrase triggered a stream of thought about my own biases and prejudices (prejudiced, moi?) and about whether it was possible or even desirable to identify and remove them all.

    In preparing this column I asked medical friends and colleagues about their work. A pathologist at the autopsy table, cupping a brain in his hands, describes his unwavering fascination with the human body: “I’ve been cutting bodies for years, and I’m still baffled by it all.” He places the patient’s organs in a plastic bag, dumps the bag in the eviscerated chest, and sews it shut. Across the room, clearing the table of clotted blood, his colleague tells me of the beauty she finds in looking at microscopic images of defective tissue. The Czech immunologist Miroslav Holub called these cellular vistas “dreaming landscapes.”4 All the while, the corpse’s eyes remain open. I try to avoid her gaze.

    Watching yet another appendix ensnared laparoscopically I ask the general surgeon if he ever tires of appendicectomies. I was bored after seeing a dozen. “Oh no!” he replied, “they’re all different.” I ask a GP colleague whether she still experiences wonder in her work, after nearly 20 years of practice. She recounts a recent house visit to an elderly couple who had devoted their lives to caring for their disabled adult children. She said: “I thought, ‘Wow! These parents are doing a superhuman job!’ That sort of case is quite unusual, but even in my everyday work I’m surprised by how people cope with a lot of shit, frankly.”

    Of all the professions, few contain as much potential for bafflement as medicine. The varied manifestations and effects of disease—be it an ossifying fibroma as large as a watermelon or the vascular devastation of a haemorrhagic fever, the fortitude of a patient faced with impending death, or the devotion of carers to fellow human beings—can each trigger a sense of wonder. We also wonder at the skill and wisdom of colleagues, whether in person or through their writings. We recall our admiration when seeing the masterly actions of a mentor: the calm composure in a moment of crisis, the brilliant diagnosis that stumped colleagues, the comforting word or look that soothed a patient’s pain. And, as Ralph Waldo Emerson noted in his essay “The Poet,” words are also actions. It would have taken me years, if not a lifetime, to acquire the insights on end of life care that Dr Joseph Fins shared in his recent book A Palliative Ethic of Care.5

    In our hectic, time starved schedule, it can be difficult to pause and ponder on the wonder inherent in our work. But it is there, and it is worth noting, lest we allow the twin threats of apathy and arrogance to calcify in our cranium.

    Notes

    Cite this as: BMJ 2009;339:b4976

    Footnotes

    • Thanks to Philip Sedgwick, Ronald P Sokol, Samantha Hettige, and Raanan Gillon for comments on a draft.

    References

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