Abraham Flexner and medical humanism, April 4, 1986

Moderator: University of Iowa, History of Medicine Society meeting of April 4th, 1986. Speaker this evening is Edmund B. Pellegrino M.D., Director of the Kennedy Institute of Ethics at Georgetown University in Washington, D.C. Dr. Pellegrino's topic this evening is Abraham Flexner and medical humanism. Dr. Edmund Pellegrino: Thank you very much, Dr. Howard, for a gracious introduction. When you talked about things rising to the surface, I could only think that fat comes to the surface. And I suspect I'll be illustrating some of the fat between my ears, as I generally do when I speak. But it's a great pleasure to be here and to be back with some old friends, Bill Bean and Bob Hardin and Palmer and to make some new friends. Particularly impressed today with the tremendously, well I can hardly describe the collection of rare books that Dr. John Martin has contributed to the university in the rare book room. I was seized with the anxiety of possibilities for cleptomania. But unfortunately, he has a sharp eye and so does his colleague. And they watched me. And of course, what they did is bring out the folio volumes. And only once did they let me get anything smaller than that a little Scribonius, which I almost made away with. But I think you're most fortunate to have that collection here at Iowa. As the director of an institute of ethics, first thing I ought to do is to be ethical myself. And I've also considered it quite immoral to break into the kind of convivial conversation you were having and to be a part of this terrible idea of the after dinner speech. I think to assault people on a full stomach is much worse than doing it on an empty stomach because the blood that's moved to lower parts of the body. The brain is somewhat deprived. And then to assault it in that condition, it seems to me, is to take unfair advantage. But I'll keep an eye on you and as I watch the signs on somnolence creeping slowly around the room, I will come to a rapid terminus. So if I suddenly close down, what is means is that you and your colleagues are falling asleep on me. And mercy will have taken the place of the desire to tell you everything I know about Flexner, which isn't very much. What I would like to do, however, is to concentrate on just one facet of this very interesting man. And I know you've had a talk already about the impact of the Flexner report, the 1910 report, I presume, on the University of Iowa. And I know that everyone here isn't entirely familiar with Flexner. Let me just say that we're dealing here with a report on medical education in 1910 by a non-physician. A report which I think has few parallels in history for the impact it has had on educational institutions. I would compare it with such things as the Ratio Studiorum of the Jesuits, 450 years of experience in liberal and classical education, with the Cardinal Newman's Idea of a University and perhaps even with the Institutiones of Quintilian. But in any case, having said that and demonstrated my familiarity with these great works, I'd say that all of us here, who are trained in medicine have been trained under the influence of Flexner. And I think that one of the aspects of Flexner, which seems to me to need examination is the fact that while he emphasized several things that have really changed medicine, one, in 1910 he really emphasized and brought it to it's attention, the need for a scientific base, which it did not have. Secondly, for a university based. Third, for a full time faculty with serious teachers. And fourth, for the control of a university hospital, which was really the laboratory for learning and research. That was not true before that time. And he made these contributions, but since that time, there has been a growing sense of unease in scads of reports. I won't document all of them, that have taken Flexner to task. Blaming him for a whole series of malfeasance on the part of medical faculties and medical schools. They said that he overemphasized science and therefore, has changed us from compassionate, caring physicians into steely-eyes, steel-rimmed glass-wearing, dispassionate, inhuman physicians. That he's caused us to ignore the social sciences and the humanities and made us narrow in our premedical education. That he's made us specialists unaware of the care of the whole person. You're heard all of these [inaudible 00:06:07]. They're very good marching songs. And they make for excellent rhetoric. And they appear in almost every report on medical education in the last 20 years, the most recent one not being an acception and I won't single it out. Some of you may have been involved with it, so I'll be very careful. And as a consequence, people have been talking for a need for a second Flexner report. We need someone to look at medical education again and everyone has tried it and come up with essentially what I would call a footnote to Flexner. But we don't need a second report. What we need to do is go back and find out in fact, what it was that Flexner said. And it's the same old story that I tried to point out at noontime today. I talked about Thomas Percival and the impression one has when one doesn't read Percival, one develops a wonderful stereotype and a caricature, which serves as the starting point for rhetorical expressions. And the same is true of Flexner. And so what I'd like to do is to say that what people find missing and are looking for is already there in Flexner, had they read the rest of his work. The 1910 report, which to remind those who perhaps are not that familiar, was a school by school examination of deficiencies, the appalling deficiencies of medical schools in the year 1910 by a very opinionated man who, thank God, didn't have a committee to work with and therefore, didn't produce the usual pap, the oatmeal without sugar or anything else that you get from commissions and reports. I'm an enemy of those things. He did point out the deficiencies. But I think that he also said some very important things about something that now is being posed as the panacea, the answer, Medical Humanism. That's the new way to deal with the difficulties of medical education. I don't mean to put it down. I've been guilty of it myself in small ways. What I'd like to do is simply to illustrate then, that all of the things we subsume now under Medical Humanism and think to be antitheses, are the Flexnerian notions about medical education that are going to somehow turn us about were in fact, included in Flexner's report. He was a much better educator and a much better humanist than he's given credit for. Now, the books to which I want to refer, and I'll mention them only, by the way, for those of you who are, and I know we have scholars among us. I'm not gonna do a Senator Joe McCarthy and say, "I have here before me ..." Those of you who remember those television programs. "I have evidence ..." but you never got your hands on it. I do have some 30 pages of trying to document what I'm saying. But obviously, I shall not read that, bore you to tears. But what I want to point out is the following, that Flexner foresaw, first of all that his work would be misinterpreted. And I'll quote from his work to indicate that. Second, he pointed out the cultural poverty of a scientific education without reference to the humanities. He pointed out the ethical problems medicine would face by virtue of the growth of its technology. And the importance and the need of the humanities to look at the questions, which science was not qualified to answer unless you're a real positivist. He pointed out that the university was the place for the dialogue that he felt was absolutely essential between medicine and the humanities. Sounds strange, doesn't it, from this presumed scientist unaware of the humanities. He thought also that medicine should be taught as one of the liberal arts. That will shock everybody and annoy some and offend some. He wasn't alone in this, by the way. Scott Buchanan, who's not received enough credit, made that point in 1938 at Johns Hopkins. And he emphasized over and over again the importance of compassion and he used the word. All of that comes down to what we are talking about today, the American Board of Internal Medicine, when it says that we ought to train or residents, and I'm not opposed to this at all, in Medical Humanism. But the board never defined it as crisply or as cogently or as sophisticated a way as Flexner did, a non humanist, supposedly. All of this comes down to a strong recommendation that medical education required to be balanced. And so if we really ought to fulfill the Flexnerian heritage, we have a job to be done that hasn't been done, the other half. How do we educate in Medical Humanism? And I'd like to say a few words about that, if I may. Let me first substantiate, at least in part, the strong statements I've been making by some quotation directly from Flexner himself. I said he foresaw that he would be misinterpreted. And he said, in effect, "That what I have said about the science of medicine," I'm paraphrasing now, "Can be misinterpreted to believe to come to the conclusion that I have no interest in the humanities." And he talks about the scientific weapons, I'm quoting now, "By means of which the causation of disease may be filtered out and health restored, which is the essence of scientific procedure. These are sometimes regarded as in conflict with the humanity which should characterize the physician in the presence of suffering. Assuredly, humanity and empiricism are not identical. With equal assurance, one may assert that humanity and science are not contradictory. It is equally important and equally possible for physicians of all types to be humane and at the same time, to employ the severest intellectual effort that they are severally capable putting forth. One can be compassionate. One can be intellectually rigorous at the same time." "Further," again, quoting, "The practitioner deals with facts of two categories. Chemistry, physics, biology enable him to apprehend one set. He needs a different apperceptive and appreciative apparatus to deal with the other, more subtle sentiments, more compassionate sentiments. Specific preparation in this direction of compassion is more difficult. One must rely for the requisite insight and sympathy on a varied and enlarging cultural experience. Such enlargement of the physician's horizon is otherwise important for scientific progress but it has also greatly modified his ethical responsibility. It goes without saying that this type of doctor is first of all an educated man." That's 1910. Again, 1925, when he reflected on the misinterpretations on his message. I won't go on and on and on. I won't overkill, but I think you should get a little of the flavor. "Now, science, while widening our vision and increasing our satisfaction, solving our problems, brings with it dangerous, peculiarly its own. We can become infatuated with progress in knowledge and control. Both of which I have unstintingly emphasized," which he did. But we lose all perspective, lose all historic sense, lose a philosophic outlook, lose sight of relative cultural values. In the modern university, note this, "The more vigorously science is prosecuted, the more acute the need that society be held accountable of the purposes to which larger knowledge and experience are turned." "Philosophers," if there are any here today, "And critics, therefore, gain an importance as science makes life more complex, more rational in some ways, more irrational in others. And classical approach to the division of the sciences and the humanities," something with C.P. Snow, unfortunately fuzzed. It was a terrible lecture, the Rede Lecture. "The differences between science and the humanities are there. They are complimentary. It is necessary they interact with each other, neither capitulating to the other." He makes this point, 1925, "But scientific medicine in America, young, vigorous, positivistic, is today, sadly deficient in cultural and philosophical background." Well, I needn't go on and on. I think there's enough here to indicate, and he has many more quotations to that effect, that Flexner would have approved of the notion of Medical Humanism. But would have, with his critical facility, have asked us to be fairly clear on what it is we are talking about. Allow me now to take a few moments with the full presumption and the pretension that goes with being a professor to try to define what I think those strains are and how we might go about it. And then close with a few more quotations from Flexner to support my point of view using him, obviously to ennoble and give better diction to my own biases. You'll recognize that without my having described it for you, of course. When we talk about Medical Humanism, now I think we're talking about two things and this comes from Flexner, of course, and from the history of medicine. Two strains, and we ought to understand those two strains. They are often confused. And they're approached as far as teaching goes, in two different ways. One is the strain of the physician as educated man. And here, generally we're talking about, when we use the word humanism, someone educated in the texts, the traditions, the values, the attitudes, the history, let's face it, of the western world. The classical, liberally educated person. The educated man, the [Ostler 00:17:40], the Keys, the [Lonica 00:17:42], the Thomas Percivals. Those people who could read and who could write and had some measure of eloquence. Those who understood the relationship of medicine to culture, to its presentation in society. Educated persons, those who were educated in the liberal arts capacity, those attitudes of mine that go with being educated, the capacity to think, to read, to write, to judge, and to judge about things more or less by those things beautiful. That's one strain. The second strain is a strain of the affective. The first was more cognitive. The second is affective. Medical Humanism as compassion. The sensitive, empathetic, responsive, warm. A physician who understands the plight of the patient, who has in fact, compassion which, going back to its etymology, compati or, the capacity to suffer along with. That physician somehow gets some insight into the uniqueness of the experience of illness and takes it into account in the way he or she functions with the patient. These two strains would have been, I think, approved in a carried forth and carried forward in those four works of Flexner. And I've just given you a little taste of it. Let's look at therefore, a few questions. First, why is it necessary at all to talk about education in these two spheres? I don't think there's any question that medical education has prepare physicians with the scientific attitude of mind. They're not scientists. We know that. Anyone who's been a true scientist knows that by and large, most medical students and most physicians have something of the language of science but are not fundamentally scientists because medicine is not fundamentally science. Medicine comes into existence when we take our scientific knowledge and we say in the presence of a sick person, "This sick person, what it is we think is best, optimal in the interests of this person. This is what you ought to do. You." Not science, not society. We're not seeking knowledge. We're trying to say to a human being, "Given your circumstances, this is what you ought to do." That's medicine. The things that lead up to may be science. They may be basic sciences. They may be social sciences. They may be the humanities. But only in that moment of clinical truth do we have medicine. Now at that moment of clinical truth, however, we're required to do two things. One is to make a decision which is scientifically, technically correct. Therefore, we must be at that moment and that phase of it, detached. This is the paradox. Detached, objective. We must be able to step back to smell, to feel, to taste, to weight, to count, to quantitate. Those things that people fear and run away from, yet medicine is dependent upon them. But we must also become passionate in the sense that we then take that detachment and convert it into what Gabriel Marcel, the French philosopher calls attachment. That is we try to put it into the frame of this person's existence. And that means therefore, that we modulate and modify our scientific conclusion by a set of values. Our own values, but above all, the values of this patient. Therefore, medical decisions need to be right and good. And the minute we use the word, good, in the moral order. Therefore, the medical decision and the medical action is one that is at the very heart, a moral one. So we need to teach detachment and we're succeeding in that. We need to teach attachment. How do you do that? Are there ways in which it can be done? I think there are and let me just go through three or four of them. I'll come back to Flexner, I'm not departing from him. I think the first, let's take the compassion element. That's the one that causes the greatest trouble. How can you teach this stuff? Well, you certainly can't teach it by lecturing the way I am, or anybody else, for that matter. I don't think I'm that bad. Others are superior. But it's very difficult. And you can lecture for six months about compassion. The most effective way, unfortunately, in some ways, is the example of a respected clinical teacher. These are the things that Flexner didn't talk about. This is the deficiencies of Flexner, if you will. Not the real deficiencies, but he didn't go into details. The example of a respected, clinical teacher. I can lecture about compassion. But I need to turn my back on the patient at the wrong moment just once and I've destroyed all of my speaking. The capacity to demonstrate to students, to faculty, to ourselves, what I was saying, that we have detachment and also try to penetrate something of the uniqueness of the experience of the illness in this person. A second way is to be compassionate in our dealing with students. This does not mean setting standards which are not acceptable. Once again, we seem to have minds that are subject to intellectual nystagmus. It's either, or. Never can we see that the polarities may in fact come together somewhere in the middle and do not abnegate each other. Demanding the standards because it's morally required but on the other hand, being compassionate and we see the failures. And when we see our own failures and admitting those failures. Helping a student to see and to feel and to go through the crises that students go through. I'm not gonna over do this. Compassionate, understanding of our fellow faculty members. Nothing is more distressing to a student than to see us parade about compassion and then to make the snide remark, the undercutting remark about our fellow faculty members. The faculty member who makes it clear that the privilege of clinical education is a privilege and not a right, and that education is secondary to patient care and so is research. Now, I have heard deans over and over again and faculty members say, "The function of a university hospital is teaching." It is not. The function of a university hospital is primary dedication to the best kind of patient care. And in that setting, the best pedagogy occurs. A very important distinction to make. And when we behave in the other way, we turn off the compassion reflexes. Supervision, one of the things that disturbs me most in my own rounding. I am a visiting professor, but quite a few places each year, which I make rounds. Is the failure to supervise, and if there are house staff here, they don't like to be supervised, but I think there's a tyranny of the house staff. A kind of, "Well, go ahead, fellas. And do it." Supervision, graded responsibility and that means that we have a responsibility as faculty members to observe that in the student and in the house staff. Instead, the house staff teaches the student. These are some of the things that in our own behavior, we can do. So that you don't think this is Pellegrino, let's talk about Flexner. Two quotes from Flexner. "The curriculum, even the rigid curriculum, is in fact, far from being the determining character of the school. The qualifications and the preoccupations, the preoccupations of the faculty are infinitely more significant. So no curricular prestidigitation will give us compassion at the beside. It isn't a matter of some new course." Although I'm gonna talk about new courses in a moment or two. Again, Flexner, "Professors of medicine," by that, he didn't mean professors of internal medicine, thank God. He meant all of us. "Professors of medicine ought to be thoroughly humane, realizing fully that they are dealing with and in that sense of fully responsible for human life." The faculty, medical teaching compassion, the first, the most effective measure. Some measures of lesser importance that can be used. Some say select humanistic medical students, change the material and you change the product. As I said at lunch today when someone asked, I think this is a snare and a delusion. I do not think that I can, despite my way of stating my position so positively and presumptively here, I don't believe I can detect at age 23 or 24 those that will be compassionate by the age 40. And I won't go into all the reasons why not, but I think they're obvious to anyone who's honestly looked at his own behavior and the behavior of an admissions committee. It's a grand lottery. We can pick up gross aberrations of character, perhaps. Failures of intellectual integrity, yes. This I do test for, rather fiercely sometimes. But not, we can select humanistic people. Medical students are bright. They learn fast and the grapevine has a communication rate that exceeds that of light. Whatever it is we say we want, we will get back. It's not that they're cynical. They're ordinary human beings, like all the rest of us. I did a study once that might interest you in this respect. And some of my colleagues remember those days. In the '60s, when we were saying, "We want clinical scientists. We want people who are scientists going in to medicine." And I read all of the essays. Every one was an incipient scientist. Oh yes, I was interested from age three and four, we had frogs in the cellar, snakes, whatever. I collected things and what have you. Then I read the essays in 1974 and '75 when the ethos had changed to primary care. And then everybody wanted to be in primary care. This is not meant to be a cynical comment. It's normal human behavior. Those who major in the liberal arts will be more humanistic. Not at all true. There's no relationship between, and I'm gonna seem to contradict this in a moment, but I'm gonna make the statement. There's no relationship between courses in the humanities and being humane and humanistic. They're far too many humanists in the history of the humanities who've been ghastly human beings. This does not denigrate the humanities, however, but we must understand why we're teaching them. Well, I can go on and on teaching the behavioral and the social sciences. We tried this for some 20 years. These things have their benefits, yes. Teaching the social sciences can raise the sensitivities, can provide some cognitive knowledge that ought to be had about human behavior, humanistic psychology, anthropological data, etc. But we're talking about a change in human behavior that has to come from a feeling which does not derive necessarily from a cause in sociology. Finally, and the most popular one, and I want to put this into perspective now, is the teaching of the humanities in medical school. Of the three or four things which probably will be permanent in medical education, and Bob Hardin and Bill Bean and I have lived through all sorts of innovations that have come and have gone. I'm not sure they'll agree with what I'll say, but at least we lived through the innovations. I think one of the few that will persist probably will be this movement that's current in the last 20 years of teaching the humanities, and I'm including ethics in that, in medical schools pari passu with a medical education. And I think that it has values, but we mustn't expect to much of it. Let's look at some of the things that are taught and how they would relate to the two strands of humanism. For the most part, they will be reinforcing that first strand, the cognitive strand. The reinforcement, refurbishment, resuscitation, Renaissance of one's liberal arts education if one had it in the first instance. Or, generating interest in it if one has not had that benefit. And it's difficult to get a liberal arts education in most college today, classical one in the sense that I've been talking about. But what the humanities can do is A, to introduce those dimensions into the scientific milieu, not to dilute the scientific milieu. I've already said, one must be competent. That's a first moral requirement. Ergo, science and the scientific notion becomes exquisitely important. As does the capacity to carry out the things you say you can do and so on. But you can improve the education of the physician and thereby make him or her a better person because, as Edith Hamilton says so well, "It's a pleasure in being educated." A pleasure. There's enormous enhancement of one's interest in life and in one's other activities. What's the most distressing problem I see in physicians in the middle years? Boredom. Loss of the zest and enthusiasm for clinical medicine and the flight into real estate, bonds, and Porsches. It's a real fact. I hope I'm not seducing the young in my telling you something that you haven't heard of before. Boredom. So we are now teaching in many of the medical schools in this country. I'm happy to have been the Director of the Institute on Humanities and Medicine. Not at Georgetown but supported by the National Endowment for the Humanities for ten years. And I visited 80 campuses attempting to work with faculties to get these things going. And so I'm drawing on those experiences now very quickly. And I'll be coming to termination, don't worry. Won't go on too long. First, philosophy being taught within the framework of a medical school. Why? Because the exercise of clinical decision making is an exercise in logic. In probabilistic logic. And if there's a defect that I see at the bedside, it's the incapacity to think clearly about the clinical situation. I sound terribly presumptuous, but I think I could demonstrate it. Perhaps even here at Iowa, I don't know. But the capacity for critical thinking, because if you reflect for a moment, a differential diagnosis is an exercise in dialectics. There comes a point in every work up when further empirical data, more facts, won't help you one bit. And then you have to carry out a critical, intellectual examination of opposing notions. That's what dialectics is. I'm not talking about Hegelian Dialectics. That's an erroneous notion, in my view. I'm sure it offended others, too. I'm talking about the Socratic Dialectic. I genuine dialectic. We have lost our faith in the capacity of the intellect to carry out that kind of activity because of the positivistic medical education we have. That's the abuse of science, not the proper use of science. And that needs to be resuscitated. It's amazing how well that does in the medical setting. Dealing with matters clinical. Literature. We have someone in the audience who's a former expert, [inaudible 00:36:34], Dick, where are you? Dick, right there. But literature being taught in 26 schools, maybe there are more, Dick, but that was my last count when I did a survey. Am I about right? Okay. Literature, I think its greatest contribution is its capacity to evoke a vicarious experience. Now, we talk about teaching empathy and my lecturing about it means nothing. But if you pick up the work of a creative writer, describing the experience of illness, the experience of death and of dying, and the world's literature's filled with these things, and go through it with someone sensitive to literature, either in poetry and prose, you can evoke in young people who've not had these experiences yet and older people as well, the thing called empathy. Psychiatrists don't teach empathy nor do psychologists. But writers do. They evoke for us. And the poets are the antennae of our civilization. They wiggle. Literature therefore, in the clinical setting, horrendous horrors that should have come before they came to medical school. What are you doing at medical school? Yes, we would have hoped that people would have had contact with literature and they have. But it needs to be reinforced, enhanced, in the clinical situation. History, the subject of your concern, most of you. I'm not gonna try, in the presence of historians, to justify history. They can do it so much better. But clearly, we do need some sense of continuity of where we are located intellectually, located chronologically, located in the vast culture of human life. Some notion of the evolution of the ideas of disease, of illness. Because they do influence how physicians function and patients respond. And while it's deprecated by the historians today, we do need some heroes. The picturesque heroes of the modern novel aren't very attractive. We do need some models, some people we'd like to emulate. And I think knowing something about great men and women is not harmful, but may not be the best kind of history. Relating medicine to the socio, cultural, historical media within which it operates. One of my own personal interests is the interaction between the dominant notions of an era, the philosophical notions and medicine, and the way medicine influenced those ideas and back and forth in a dynamic equilibrium. Ethics. Ethics turns out to be the most frequently taught. For the very clear and obvious reason that medicine is, as I say, fundamentally at its heart a moral enterprise. We must make decisions which are good and therefore, you've got to know what good is and to be able to critically analyze it. And I submit to you that one cannot be a physician properly speaking, physician now, when he can be a radiologist and a gastroenterologist or whatever. But a physician defines, as I did earlier in that moment of truth, unless one can in fact, analyze with the same degree of rigor, the value [inaudible 00:40:29], the ethical question at the moment of decision making. And that, I think is something new. Medical ethics 20 years ago was taught pretty much as a set of rules that you follow. We're talking now about how do you critically analyze the value question? Where do you stand? Where does the patient stand? How do you resolve the difficulties in a morally defensible way? So what we try to do in ethics is to teach skills in ethical analysis. Provide a knowledge of the varying points of view on how one resolves a particular ethical dilemma. There is a literature, as in any other field. Also, perhaps most important of all, to enable the student and ourselves in the analysis to look more deeply and to understand the configuration of our own values. Because we are, to a large extent, defined by our values. Our values being those things we're willing to work for, suffer for, die for, pay for. The things we use as the justifications for our actions. So we're rather critical of each other. Why and how did we do that? And sometimes, it's painful because we have to expose our deepest, fundamental, and I don't blush to say it, our theological and religious belief systems. Because for many people, they are exquisitely important. If they aren't for the physician, they are for the patient. And to look at those without blushing. Ethics has a value, therefore. It's one of the humanities, the branch of philosophy. Things can be done, therefore, with a teaching of the humanities will not assure compassion. I go back to what I said, compassion is learned by the compassioned behavior of someone you respect and by drawing on the experiences you've had up to that point in your life in your home, in the school, in the church, wherever. And finally, perhaps most important of all and most difficult to assess, for many people, the intrinsic values of the humanities. I have been emphasizing their pragmatic applications because we're pragmatists in medicine. We want to know why you should do this. But clearly, as I said, this question of boredom, the question of enriching one's own life experiences, more important than that, in a way, having some source of intellectual satisfaction beyond the profession itself. It needs, sometimes, to be modulated. And I don't care what it is. Whether it's art or music or whether it happens to be philosophy or literature. But note, I say, intellectual. So those are the virtues, perhaps, of teaching humanities. Let me close by a series of quick quotations now, from Flexner. So that again, you get more Flexner than Pellegrino. Flexner made a very strong plea for placing medical education in the university. Two of them, I won't comment on. One was the need to imbibe the spirit of research. Medicine has been doing that. Not always perfectly, but extraordinarily well. Second as a place for that dialog and dialectic between the sciences and humanities. I've been at six universities and the most difficult thing to get going is an academic discussion across disciplinary lines. It's a sad commentary on the education of all of us as faculty members. But I'll pass that bias, [inaudible 00:44:39] to say, I shall pass over that fact. Rather, the third reason is to liberalize, that is to make a more liberal education of medical education. That is to say, to make it a more intellectual adventure. In the best medical schools that I've been in, I've had the recurrent experience of students coming to me, and I know I'm saying things that will offend, perhaps, but I don't mean to be offensive. And have said, this is an unintellectual experience. And they've been right. And I don't have a tendency to agree with students just because. In fact, my adulation for youth is sometimes questioned. When I was at Yale, it was the major complaint of the best students. I'm not gonna say anything about the other places. Yale can take it. Okay, what does Flexner say about this? Well, for one thing, hear this. "The medical curriculum cannot therefore, be encyclopedic. It cannot be organized from the standpoint of facts or knowledge. To be sure, the student needs to know somethings well," we all know that, "In order to be able to observe, compare, and infer," notice, intellectual activities. You're not talking about amassing facts, but attitudes of mind. Now, I think the notion of problem solving is a rather unsophisticated way of saying that. I have to be very careful about what I say, but that's an unsophisticated way when I pin those people against the wall, it's pretty squishy. "Which always involves knowing particular things well." He thinks all of that is more important than the knowledge of any particular set of facts. "It is clear, therefore, from reflection as it has been made clear by experience, that a selective and varying, not an encyclopedic or uniform, a lightly laden, not a too crowded curriculum, offers the best opportunity for the training requisite to mastery and growth." Now, some will say, "That's the GPEP Report." I don't want to offend anyone about the GPEP Report. But it doesn't have Flexner's understanding of what it means to compare and to infer. He's talking about a true education and not something called problem solving. "His aim was to equip," I'm quoting from Flexner, "To equip students with disciplined minds." That doesn't mean that everything a student says because he said it is good. We ought to be kind with error. "Students should be left to their own devices." How many times are the students left to their own devices in our curricula? And he warns, that, "Those who sacrifice broad and deep university experience in the long run find themselves intellectually and vocationally, and vocationally, disadvantaged." Well, we won't go on and on. Let me just say, I think we have a Flexnerian task still to be done. Flexner's spiritual heritage to us, lectural heritage, is one that's consistent with the recognition of a need for something called Medical Humanism. 75 years after his report, I think his writing and his thought is still vibrate. It's still vital. It's still on target. He isn't the prophet who brought us into the desert of a narrow, fact-packed anti-humanistic medical curriculum. That's a comfortable straw man for the curricular prestidigitators. If we're in the desert, it's because we have taken to heart only half of his educational legacy. We have to bring the other half to fruition. Or, and the only alternative, is to continue our periodic spasms of educational anxiety and to continue to write footnotes to Flexner while ignoring the text from which those footnotes spring. To reconcile technology, science, and humanism is today's Flexnerian task. We don't need another report. We need to cogitate what he has said. And I think that we ought to at least those of you who think there may be substance to the claims of Flexner's anti-humanism, please read beyond 1910 and 1912 to 1925, his Comparative Study of Medical Education and 1930, even better, his text on universities, English, American, and German. Thank you very much ... Dr. R. Palmer Howard: I don't want to take the podium from Dr. Flexner. Not just yet. We've obviously thanked him. I'm sure there are a couple of students, maybe, with a question. Takers from the students? Dr. Edmund Pellegrino: Well, faculty can get into this, too. Dr. R. Palmer Howard: Well, I know, but I wanted to see if there was a hearty student. No? I think the students may be at a disadvantage, being asked a question in the presence of the faculty. Well, all right. What about the non medical faculty now? We've got a lot of non medical faculty here. And I'd like to see if we can get a question from ... Dr. Edmund Pellegrino: Well, I'm certain there must be disagreement. Dan? Dan: [inaudible 00:51:12] more pointed comments about the misinterpretation of his reports? Dr. Edmund Pellegrino: No, just want he said, that was the beginning of 1925 report. 15 years later, I quoted one long passage. He has a number of others. It's in the first chapter of his 1925 book, on Comparative Study of Medical Education. He was painfully aware of the fact that he was misinterpreted. Even that early on. Yes sir? Audience Member: Why do you supposed the point got missed if he did indeed get misinterpreted? Dr. Edmund Pellegrino: The points that I've been making? The point I've been making? Well, I think there are a number of reasons for it. Let me speculate for a moment. And I'll do it very quickly. One, I think the tremendous successes of the scientific method applied to the bedside. Overwhelming, really, of those who lived through it, it was tremendous. And it was very easy then to feel that, that was the heart of the matter. And anyone didn't have to look at the other aspect. The second was the deterioration of the liberal arts education. The fact that humanists became themselves, specialists and professionalized. And defected from their major contribution to university, which is to be the teachers of us all. I think those two things, clearly. The third was a growing notion of the fact that a true liberal education in the humanities were elitist. Forgetting that elitism is a good things as well as a bad thing. Elitism is a bad thing in the political sense, but there is not such thing as equality of ideas. There are good ideas and bad ideas. Well defended ideas and poorly defended ideas. But that notion, I think. Those would be three quick speculations. Perhaps you have better ones or other ones. What do you suggest, perhaps? Audience Member: [inaudible 00:53:20] Dr. Edmund Pellegrino: Yeah, okay. Well, those would be my quick responses. Dr. R. Palmer Howard: Do you think that happened in ... The last one interests me and that is that the humanists, teachers of the human sciences, human sides of the liberal arts colleges separated themselves from the [inaudible 00:53:45]. Do you think this occurred in the European universities as much as in [crosstalk 00:53:49] universities? Dr. Edmund Pellegrino: Oh, yes. Certainly. Although they had a stronger tradition than we did. And Europeans, by and large, had a more rigorous early education. But I think that's also in the past 10 or 15 years, that's been eroded very seriously. In my conversations with those who seemingly know, I've only been to Europe half a dozen times to talk about this sort of thing. Dr. R. Palmer Howard: So the two groups need to get together more and more. Dr. Edmund Pellegrino: Well, I think what's happening, as always happens, it's not the professionals who become aware of their deficiencies. Professional organizations, professions, medicine, law, teaching, so on, are self contained, [inaudible 00:54:35] producing organizations that exert as much energy as they can possibly to stay still. And I don't mean that just figuratively. The outside world changes. It's changed in medicine, you see. People are aware of the fact that what the physician decides makes a tremendous difference now. A, we have tremendous capability. B, we can't be allowed that power without external surveillance. People understanding the value conflicts that may occur. And, in a morally pluralistic society, which is what we are, being interchanged with a physician and a patient on the most vital issues may be one in which there's significant conflict. And in a Democratic, pluralistic society, you cannot go on with a paternalistic notion such as we had in the past, which is not the same as an elitist notion. So I think that ... Dr. R. Palmer Howard: Let me just call on one more. Oh, Dr. [Sebaum 00:55:36], well, I'll call on two more. Would you like to ask a question? Excuse me. No you, you. Audience Member: I'm a Christian medical student. And the one thing, how do you supposed Flexner would compromise the so-called information explosion? At least, I've seen it this year. There's tons and tons and tons of things to know. And recognizing you're never going to learn it all or as well as you'd like to. And plus, trying to add medical humanities, how do you think he would sort of [tragically 00:56:11] implement what? Dr. Edmund Pellegrino: Well, I wouldn't have to ask Flexner. I can tell you how it's done by others. One, first of all, I should disabuse you of, I'm sure, some conclusions you've jumped to, which wouldn't be unfair, given the fact that I have not been able to go into great detail. First, we're not suggesting, I wouldn't suggest the notion that we can develop a Renaissance man. There never was such an animal. Leonardo Da Vinci, maybe a few others. But that was another one of those romantic notions we established and we're not asking for that. But when you have a large book of information and knowledge, the only way you can get on top of it is by organizing it. And I think the great plight of the medical student is not knowing where the hills and the valleys are. It isn't all important. And unfortunately, the way we teach today, no one teaches a course in a medical school. It's a gang approach. So you get small molecules, large molecules, enzyme kinetics, metabolism, etc. I'm not depreciating the importance of expertise. I've got my own little field of crystallography in which I fool around, too. And I think it's the most important thing in the world. But when I get serious, I realize it's not terribly important. But you ought to know a little bit about it. But I think one of the great improvements we could make would be if we would have someone teach a course in biochemistry. And teach a course in physiology. A person. One of the great revelations to me, as a medical teacher for 35 years was when I joined the Department of Philosophy and had to teach my own course from A to Z. And I had to know what I wanted to teach, what was important, what I would leave out, what were the readings. And I was responsible for the whole course. Now, those in the humanities faculties, may say, "Boy, that's an interesting revelation." But those who teach in medical schools know that we teach a piece of the spectrum. And it was a revelation to me. I've enjoyed it. I think we could do that. So I'm not speaking for Flexner. I can't, thank God. The poor man can't be here to defend himself. But that's my response. He did say that when you have a mass of facts, selectivity. Now, you're gonna tell me, "We can't tell which fact we might use 15 years from now." Don't worry about it. Have that disciplined mind that knows how to put these facts in order. And then you will add, after all, every clinician here knows that if he or she has stayed ahead of the game, it's been by self instruction and bringing into your knowledge base, those things that are relevant to what you do. And the fact that, when I went to medical school, citric acid cycle was a footnote in Bondansky's textbook of chemistry. And they said you didn't have to know it. I don't think was an immoral act. I did learn about it and it became important for me to know about. Why? Because, thank God, I think and so did all my colleagues that stayed abreast, had an education that trained them to have disciplined minds so that you're not worried about whatever you're presented, which you can put it into some kind of order. I suppose I ought to end this by quoting my mentor, Thomas Aquinas. Some of you may have suspected that already. He said, 'Intellectus soleus est ordinare,' "The sole, the prime purpose of the intellect is to put things in order." That's what we have to learn how to do. And the computer age doesn't help you with that ... Dr. R. Palmer Howard: Would you like to say anything, Paul, before we break up? Paul: The only question I would have, [inaudible 01:00:29] is that I guess that Dr. Pellegrino, given that we had 120 Dr. Pellegrinos, and we were to set up in the medical school the ideal ethics and humanitarian department, how would it be designed and operated to meet the modern demand for humanism, which is really been with us [inaudible 01:00:56]? Dr. Edmund Pellegrino: Well, obviously I won't describe the ideal, because it doesn't exist. But why don't I just say a few quick words about what in fact is being done in most places rather than ... I think most places now, when I say most places, but in the last survey, it was 110 schools, do the following. As far as ethics goes, I'm leaving out literature, history, and so on, because each of them has its own requirements. But they try to do, as I said, have the aim and objective of ...