by David J. Elpern, M.D.

Abstract: Physicians waste too much time mired in our pedantic and mediocre professional literature. There is no way one can keep up with it and most of the articles are forgettable and sadly will prove to be inaccurate. It is better to spend time with the arts (literature, music, fine art, film) that are more important to one’s personal and professional development. They provide the Continuous Medical Inspiration that trumps Continuing Medical Education.

Keywords: medical education, canon, personal canon, literature, fine art, music, William Osler, medical literature, CME

Each week physicians and other caregivers peruse their professional literature.   We also gather regularly at Grand Rounds to hear visiting firemen pontificate from the podiums. Occasionally, these articles and talks are heady and stimulating. However, most of what one reads or hears will be proven wrong and, sadly, is not memorable. What great talks did you hear in the past six months? Which recent articles are sticky? One expert tells us that the incidence of melanoma is up; while another opines that the death rates from melanoma have not changed in the past thirty years. Too many “experts” turn out to be key opinion leaders (KOLs) who are paid handsomely for their proclamations by pharmaceutical companies even though their conflict of interest statements do not reflect that. Too many articles have been ghost-written by PhRMA.¹

The National Library of Medicine (NLM) indexes over 5000 medical journals. In my specialty of dermatology, NLM receives more than 120 dermatology journals; it indexes 58. Who could read these even if all one did was pore over skin journals? And how valuable a use of our time would that be? John Shaw Billings, the architect of the NLM and creator of MEDLINE wrote: “There is a vast amount of effete and worthless material in the literature of medicine. Our preparers of compilations and compendiums, big and little, acknowledged or not, are continually enlarging the collection, and for the most part with material that has been categorized as ‘superlatively middling, the quintessential extract of mediocrity.”²

John Ioannidis, an infectious disease specialist at Stanford and the University of Athens, goes one step beyond Billings. His 2005 paper in Public Library of Science – Medicine (PLoS Medicine), “Why most Published Research Findings are False,” is the most downloaded article in the history of PLoS and has been described by the Boston Globe as an instant cult classic.³ Ioannidis estimates that 90% of the research reported in the medical literature will be proven false. As a mathematician he offers an elegant proof.

According to Ioannidis, most of the material published in the medical literature is, or will be proven, false and according to John Shaw Billings, most published articles are forgettable and not worth our time. In addition, many of our most “respected” leaders are, or have been, co-opted by lavish perks from Big PhRMA. That’s the depressing reality. So how should a sentient physician proceed? What is worth her time?

2400 years ago, Hippocrates said:

Life is short,
[the] art long,
opportunity fleeting,
experiment fallible,
judgment difficult.

This still rings true. I would like to suggest how health professionals might better spend their time in the pursuit of continuing medical inspiration (CMI), which is different from continuing medical education (CME).

Dr. Jonathon Hullah, the protagonist of Robertson Davies’ novel, “The Cunning Man” proclaims, “More humanism and less science; that’s what medicine needs. But, humanism is hard work and a lot of science is just Tinkertoy.”⁴ While extreme, this is accurate.

In a similar vein, the English teacher, John Keating, in the movie, Dead Poets Society, tells his students, “We don’t read and write poetry because it’s cute. We read and write poetry because we are members of the human race. And the human race is filled with passion. Medicine, law, business, engineering, these are noble pursuits and necessary to sustain life. But poetry, beauty, romance, love, these are what we stay alive for.” Over the years, this has become a mantra for me.

In his essay on John Keats, William Osler quotes James Russell Lowell: “We reward the discoverer of an anesthetic for the body and make him a member of all the societies, but him who finds a nepenthe for the soul we elect into the small academy of the immortals.”⁵

And the physician-poet, William Carlos Williams in his long poem Asphodel wrote:

                           Look at
what passes for the new.
You will not find it there
but in despised poems.
It is difficult
to get the news from poems
yet men die miserably every day
for lack
of what is found there.

Over twenty years ago, I asked myself “will you spend your life lost in a sea of minutiae, most of it untrue and unremarkable, or will you try to find some Truth on this planet? Truth handed down over the millennia by mentors culled from members of the Academy of the Immortals, not from my professional society!

This is not a new idea. The Roman poet, Horace (65 BC – 8 BC), wrote: “omne tulit punctum qui miscuit utile dulci, lectorem delectando pariterque monendo. (He wins every hand who mixes the sueful with the sweet, by delighting and instructing the reader at the same time.)

Great literature is sweet in that it delights our senses, but it is also pregnant with meaning. William Osler, befitting his times, was more controlling than today’s professors, and so he directed his medical students at the new Johns Hopkins Medical School to read certain books for a half hour before retiring in the evening. This was the genesis of his Bedside Library.⁶ Today, his list is sadly dated. (A list of Personal Canons from a number of my colleagues can be found on the Personal Canon Blog)

(this image is from: http://greatbookstudy.blogspot.com/)

The internist Nicholas Davies wrote a fine piece for the British Medical Journal in 1989, confessing his “Reading Binges.”⁷ It is well worth perusing. In this essay, Davies described his annual reading binges. Each summer he spent a week in pleasurable bondage to the world’s great literature. He usually stuck to the classics or books that were likely to become classics. Since each of us has only a finite number of books to read, it seemed important not to waste one’s time with drivel.

There are many books that can help one choose what to read. Harold Bloom wrote, “The Western Canon.” The novelist, Francine Prose, whose mother and brother were dermatologists wrote “Reading Like a Writer.”  Robert Coles wrote a fine book, “The Call of Stories. The novelist Pat Conroy recently published, “My Reading Life.” For me, the most important work in this area is Mark Edmundson’s seminal book, “Why Read?”⁸ In it, he writes:

This book is written for the student and potential students of literature—to all those who might dream of changing their current state through encounters with potent imaginations.

Edmundson tells us that “Much of what teachers can offer, you can provide yourself. It is often a simple a matter of knowing where to start.” He goes on:
Two related activities are central to a true education in the humanities. The first is the activity of discovering oneself as one is in great writing. The second, and perhaps more important, is to see glimpses of a self, and too, perhaps, of a world that might be, a self and world that you can begin working to create.

He believes that universities and colleges are not places for personal growth but have become warehouses for training and entertaining. Their goal should not be to distract students but to make them better people.

After studying Edmundson’s book, I decided to evaluate my own “postgraduate education” at the feet of the masters I have selected as my Immortal Mentors and came up the idea of generating my own personal canon (Figure). Gradually it dawned upon me how idiosyncratic one’s canon is and how it can change over time. While Osler prescribed a Bedside Library for his students, it would be hubristic for today’s today to mandate a canon to others. Each of us has a personal canon that guides us in our private and professional lives.

References:

1. Chabner BA. Ghost writers in the sky. Oncologist. 2009 Mar;14(3):199-200. Full Free Text

2. Billings JS. Our medical literature.” Boston Medical and Surgical Journal 105 (1881): 217–22.

3. Ioannidis J. Why most Published Research Findings are False. PLoS Med. 2005 Aug;2(8):e124. Epub 2005 Aug 30. Full Free Article

4. Davies R. The Cunning Man. McClelland and Stewart. 1994

5. Osler W. John Keats: The Apothecary Poet. in The Alabama Student and Other Biographical Essays. Oxford University Press 1909

6. Osler W. His Bedside Library. Cell2Soul.Typepad

7. Davies NE. Reading Binges. BMJ. 1989 Nov 11; 299(6709): 1209–1210.

8. Edmundson M. Why Read? Bloomsbury 2004

Figure

From an Ample Nation
Recommended Readings of David J. Elpern, M.D.
Dermatologist
Williamstown, Massachusetts

1. The Complete Poems of Emily Dickinson
   Emily Dickinson has guided me for decades. One can read them as refreshing snacks, or reread them years later and see new levels of meaning.

2. The Life of William Osler by Harvey Cushing
   Won the Pulitzer Prize in 1926. It’s a thick tome – over 1300 pages long. Osler comes across in these pages as a scientist, a clinician, a bibliophile, a jokester, a humanist and much more. Well worth the effort

3. Medical Nemesis by Ivan Illich
   This is one of the first modern books to inform the public about the juggernaut that is the Health Care System. The thesis is stated early in the book: “The greatest threat to the health of the commonweal is the medical profession.

4. Man’s Search for Meaning by Viktor Frankl
   Among the most influential works of the 20th C. Frankl writes. “After all, man is that being who invented the gas chambers of Auschwitz; however, he is also that being who entered those gas chambers upright, with the Lord’s Prayer or the Shema Yisrael on his lips.” A must read.

5. Closing the Chart by Steven Hsi
   Written while the author was dying of Takayasu’s aortitis, this is profoundly moving and important. It gives caregivers and patients an insight into the country of the ill and teaches even seasoned health care providers many lessons we were never taught.

6. The Care of the Patient by F. W. Peabody
   Peabody’s essay is the most important article on patient care ever written. All care providers should read it every few years.
7. A Taste of My Own Medicine by Edward Rosenbaum
   This gem was made into the movie – “The Doctor” – and predictably, the book is much, much better. In it, an elderly rheumatologist chronicles the lessons he learned when he developed laryngeal carcinoma. He is a gentle man with profound insights and the book will enrich students and physicians alike

8. Middlemarch by George Eliot
   Arguably the finest novel in the English language. It takes a bit of discipline but is brilliant, captivating, memorable..

9. One Hundred Days by David Biro
   A memorable and important read. In clear, compelling prose, the physician-author describes what it felt like to undergo a bone marrow transplant and to endure the agonizingly slow, painful and depressing period of recovery.

10. P.S. Julia by J. Fox Garrison
    I “discovered” P.S. Julia quite by accident. It moved me greatly and I think it is a must read for patients and all care givers. Every day, I see patients who would benefit from sitting at Julia Fox Garrison’s feet.

 Lagniappe:
Why Read? by Mark Edmundson
Edmundson tells us that: “The purpose of a liberal arts education is to give people an enhanced opportunity to decide how they should live their lives” and that literature is “the major cultural source of vital options.” This book opens one’s eyes and makes one feel as Keats did, “like a watcher of the sky/When a new planet swims into is ken.”