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Point of View

Faces as well as facts

By Antonia Novello, M.D., Dr.P.H.

It troubles me that so much of medical school is spent in the drudgery of memorizing facts and so little in the conceptual teaching of medicine, prevention, and common sense. Of course, facts are necessary. They are the building blocks of knowledge. However, facts change.

I see the true purpose of a medical education as not merely accumulating facts but creating habits of mind. Doctors must be humble about what facts they do not know. Socrates said that if he was wiser than anyone else in ancient Greece, it was only because he knew what he didn't know. This is why I prefer to evaluate doctors not as much on the answers they give, as on the questions they ask.

The decades ahead will be filled with societal and technological changes that will challenge those who practice medicine. Dealing with these challenges will certainly require working hard. But it will also require keeping an open mind, maintaining a sense of curiosity, studying the arts and the humanities as well as science and technology, and sustaining compassion for all human beings. It will require being wary of avarice, ambition, envy, anger, and pride. It will require, as Rabbi Harold Kushner has put it, avoiding complacency, mediocrity, and, above all, indifference.

Remember: I believe doctors should also heed the words of Dr. Grover Powers, one of the pioneers in the field of mental retardation, who stated nearly 40 years ago: "When there is no cure, the doctors sometimes capitulate too easily to therapeutic defeatism—forgetting that the physician is just as responsible for alleviating as for curing." Even in the 21st century—with medicine practiced at genetic, cellular, and molecular levels, utilizing sophisticated biotechnological instrumentation—we must remember the faces behind the numbers, the people behind the statistics.

Caregivers need to be mindful as well that of this country's 298 million people, 38% are minorities, 12% are over the age of 65, and 10% speak a language other than English. The U.S.'s rapidly changing demographic profile carries important implications for medicine; it means the

Even in this new millennium, with all its therapeutic marvels, health is still enhanced by a healing touch or caring word.

profession cannot cling to rigid, outdated practices once accepted by the mainstream.

And doctors must understand the impact of societal factors on their patients' health outcomes. Multiple studies have shown that 50% of untimely deaths could have been avoided by changes in risktaking behaviors. Such behaviors are all too often blamed on the individual, yet they occur within the context of a social environment. Risky behaviors tend to be higher in communities where poverty rates are high, housing is substandard, education is poor, social support services are inadequate, and jobs are unavailable. In other words, health problems don't exist in isolation.

So doctors must seek to know all aspects of their patients' lives before inserting them as mere statistics into action plans for the delivery of care. To deliver truly effective care, they must understand not only disease management but also cultural sensitivity. They must learn the importance of discovering where their patients come from and what they've been through—and not just from a medical history on a reception-room questionnaire, but their broader experience of human (and inhuman) living, their total persona, their humanity. Patients don't care how much their doctor

knows until they know how much their doctor cares.

Lags: Another challenge for the profession is that on nearly every indicator, the health of the nation's minorities still lags well behind that of the majority. For example, life expectancy for an African American baby boy is seven years less than for a white baby boy; the diabetes death rate for Hispanics is 40% higher than for non-Hispanic whites; and African American, Hispanic, and Asian American women wait twice as long as white women for diagnostic tests following abnormal mammograms. These health disparities are related to a multitude of root causes, including income, education, employment, and, sadly, even discrimination in the health-care system.

The reality is that students come to medical school filled with 25 years of life experiences, and in this society those experiences often involve situations where racial and gender bias is present. Medical training needs to address these biases, or they will result in bad clinical decisions. This nation must not tolerate a two-tiered system of care, with a gap between the haves and the have-nots. If America is to be great for any one of us, then America must be great for all of us. As Franklin D. Roosevelt said: "The test of our progress is not whether we add to the abundance of those who have much. It is whether we provide enough to those who have little."

Doctors have a unique opportunity to serve the disenfranchised—the young, the poor, the disabled, the elderly—by improving their health in a manner that is deserving of trust and respect. It is important to remember that even in this new millennium—with all its therapeutic marvels, machines, and gadgets—health is still enhanced by a healing touch or a caring word.

Obligation: Yes, health-care professionals certainly have an obligation to advance the technology and science of medicine and to advocate for needed research; technology has brought about many benefits. But it is just as important to preserve the human element of med-icine. Although society and our health- care system have changed, patients' vulnerabilities and needs have not.

The "Point of View" essay provides a personal perspective on some issue in medicine or science. Novello,a former U.S. surgeon general, is now health commissioner for the state of New York. This essay was adapted from a talk that she gave to DMS graduates at this year's Class Day ceremony; see the article "Class Day 2006" for a few more of her Class Day remarks.

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