Calling Dr. Thomas

Lewis Thomas’s autobiography is, in many good ways, a deceptive book. Its two parts read, superficially, like a reverie, full of cozy nostalgia celebrating a life well lived. The first section describes his father’s career as a general practitioner in Flushing, New York City—my old stomping grounds when I was a boy, and well remembered as densely urbanized in the late 1940s, but virtually a rural village during Thomas’s youth. We read of horse-drawn carriages, home visits, endless concern, and little pecuniary reward. The second section treats Thomas’s adult career as a doctor and medical administrator. He transmits an overwhelming impression of the fun that research can be, and he even manages to intimate that administration can be more rewarding, even more amusing, than frustrating—a proposition that I find hard to believe.

Yet in many ways, and despite its overt content, The Youngest Science is a profound and even disturbing book. Both its parts are fundamentally about trade-offs made necessary, and surely in large part desirable, by improving technology—specifically, the sacrifice of heart for efficiency. Dr. Thomas, Sr., and his old medicine could do precious little to cure disease, but his ministrations were often effective because his personal concern and endless attention inspired confidence. In the second part, Thomas describes his own research as especially enjoyable, and perhaps even more effective, because its small scale, and the limited resources that make a senior researcher scrounge for equipment and do the routine procedures himself, guarantee a closeness to detail that may be all for the good (ethically and factually). By contrast, modern heads of laboratories command vast empires and often never sit at a work-bench. Vastly more work can be done in a given amount of time, but senior researchers can so lose touch with the day-to-day procedures of their laboratories that the fraudulent data of a Darsee can go undetected for years.

Thomas is able to insinuate these serious themes into a charming and superficially rambling narrative because he has been perfecting this technique for years in the two books of essays that have made him a popular figure—The Lives of a Cell and The Medusa and the Snail. Thomas’s essays are unsurpassed for their uncanny knack of starting with a simple fact, a bit of home-grown Yankee wisdom, and slyly developing its implications until some profound truth slips through before you hardly notice. Thomas has now successfully pursued this strategy into book length.

I was enthralled by the book’s first part, probably because I harbor memories of what may have been the last years of physicians’ home visits in my own version of Flushing. (I distinctly remember how Dr. Schildkraut’s arrival to treat me for flu once interrupted my fascination with the radio news of King George VI’s death.)

Dr. Thomas, Sr., began with a bicycle, then graduated to a horse and buggy and finally, a year before Lewis’s birth, to an automobile. He never had an office nurse or secretary. He kept office hours at home from one to two in the afternoon and from seven to eight in the evening, seeing an average of ten patients each hour. The rest of the day he was on the road, making rounds at the local hospital early in the morning and performing his house calls throughout the rest of the day. At night, long after the rest of his family had gone to bed, he kept his accounts and fretted over the characteristic late (or non) payment of most clients. All this was interrupted at least once, and often three or four times each night, by emergency calls requiring more house visits. Lewis Thomas remembers how his father would usually swear “Damnation” under his breath, and how he sometimes even got angry enough to exclaim, “God damn it.” Yet he always went.

The monetary rewards for all this were modest. Thomas’s best friend in the Harvard class of 1937 put out the yearbook and sent a questionnaire to Harvard medical graduates of the previous classes of 1927, 1917, and 1907. The average income for the ten-year graduates was $3,500, rising to $7,500 for the twenty-year men. “One man, a urologist, reported an income of $50,000, but he was an anomaly; all the rest made, by the standards of 1937, respectable but very modest sums of money.” Medicine, the old saw went at the time, was an honorable profession, but hours were long, monetary reward modest, and effectiveness limited.

Limited effectiveness is perhaps the most striking difference between medicine then and now. It is also the source of Thomas’s title, The Youngest Science, since it was only with the introduction of the sulfa drugs in the late 1930s and penicillin and other antibiotics a few years later that doctors finally learned to treat and cure more than a very few diseases.

Old Dr. Thomas, for all his efforts and hours, could do very little to help his patients directly. Lewis Thomas describes his childhood conversations with his father, who often took him along on house calls:

The general drift of his conversation was intended to make clear to me, early on, the aspect of medicine that troubled him most through his professional life; there were so many people needing help, and so little that he could do for any of them. It was necessary for him to be available, and to make all these calls at their homes, but I was not to have the idea that he could do anything much to change the course of their illnesses.

In those days, a doctor’s reputation as healer was assured because we all slip so easily into the post hoc, ergo propter hoc fallacy. Most diseases run a natural course and few lead to inevitable death. Thus large numbers of people will get well, regardless of what ministrations doctors provide. But the belief that a doctor’s attention makes a difference—especially back in the old days when they came to your house, knew your dog’s name, and spent endless time in encouraging discussion—can be powerful, especially when that attention is followed by a natural recovery. This situation remained right through Lewis Thomas’s time in medical school. He writes of medicine just before the introduction of sulfanilamide:

It gradually dawned on us that we didn’t know much that was really useful, that we could do nothing to change the course of the great majority of the diseases we were so busy analyzing, that medicine, for all its façade as a learned profession, was in real life a profoundly ignorant occupation.

With the exception of morphine and digitalis, most of the drugs in his father’s arsenal were placebos, but none the less effective for that. The “placebo effect” is one of the most interesting phenomena in medicine. Some placebos “work” because people are getting better anyway, but states of mind inspired by confidence clearly influence the course of health in other cases. Placebos sometimes really make a difference, if we have confidence in the doctor—hence the secret of effectiveness for the old-fashioned approach designed to inspire such faith. Thomas writes of the mystery and ritual involved in writing prescriptions, invariably in illegible Latin:

They were placebos, and they had been the principal mainstay of medicine, the sole technology, for so long a time—millennia—that they had the incantatory power of religious ritual. My father had little faith in the effectiveness of any of them, but he used them daily in his practice…. They did no harm, so far as he could see; if nothing else, they gave the patient something to do while the illness, whatever, was working its way through its appointed course.

It followed that the principal goal of practical medicine became accurate diagnosis, rather than treatment or cure. If medicine could do little to alter the course of most diseases, at least it could tell a patient what to expect, and explain his chances and probable progress with accuracy and compassion. Thomas writes of his own training: “Our task for the future was to be diagnosis and explanation. Explanation was the real business of medicine. What the ill patient and his family wanted most was to know the name of the illness, and then, if possible, what had caused it, and finally, most important of all, how it was likely to turn out.” Of a master doctor and diagnostician, he writes: “So far as I know, from that three months of close contact with Blumgart for three hours every morning, he was never wrong, not once. But I can recall only three or four patients for whom the diagnosis resulted in the possibility of doing something to change the course of the illness.”

This doesn’t mean that medical men didn’t try a variety of methods to alleviate disease. But most were useless fads, and Thomas tells some amusing stories. In the first decade of this century, the notion arose that most human disease might be attributed to the absorption of toxins from the lower intestinal tract. This “autointoxication” could be countered by keeping the large bowel empty, and a variety of devices were introduced to assure such regularity. In 1912, Thomas’s father bought a curious item from a medical supply house—a large lead object the size of a bowling ball, wrapped in leather. The patient would lie flat in bed and, several times a day, roll the ball clockwise following the course of the large intestine. Needless to say, it didn’t work, and Thomas, Sr., eventually threw it out. Twelve years later, the local newspaper announced the discovery of a cannonball from the Revolutionary War, unearthed in the garden behind the Thomases’ neighbor’s yard. No one could figure out how it got there because it followed no known trajectory of any engagement from that war.

As a result of purely personal prejudice, I found the second part of The Youngest Science, Thomas’s description of his own professional life, less interesting than the first. Thomas has done some important research, primarily on immunological questions, but he has spent most of his life as a medical administrator, in a long and impressive series of deanships and directorships of such institutions as NYU, Yale, and the Memorial Sloan-Kettering Cancer Center. Now I know that any institution would fall apart without its officers (the key person, as Thomas would readily admit, being the chief administrative secretary, not the boss), but I’ve never been able to develop much interest in the process, however indispensable it may be. In part, Thomas himself identifies the source of my malaise: a well-oiled place is best served by being left alone.

The governance of academic institutions has been considered and reconsidered, reviewed over and over by faculty committee after committee, had more reports written about it than even the curriculum, even tenure. Nothing much ever comes of the labor. How should a university be run? Who is really in charge, holding the power? The proper answer is, of course, nobody.

If there were real answers, someone would have figured them out by now, since universities are usually run by people of reasonable-intelligence and good will. So the only exit from the dilemma must be an admission that there are no good, or unambiguous, solutions. And you can only write so much about such matters.

Thomas had more latitude with some of the purely medical institutions that he has managed, and here his descriptions are more engaging and insightful. They form, at a personal level, a good counterpart to such academic treatments of the subject as Paul Starr’s recently published and highly praised Social Transformation of American Medicine.^* I enjoyed the chapters on Thomas’s research even more—especially because he discusses his failures as much as his successes and continually emphasizes the pure fun of research. As any practitioner knows, the effort of research is so tedious and time consuming that when it stops being fun, there’s no sense in continuing. The most famous of all scientists live a life of keen amusement.

Underlying all this pleasant discussion is the persistently serious theme of crisis, or at least lamentable loss, in the trade of personal attention for high technology in the practice of medicine, particularly at large hospitals (which, as Thomas stresses, he knows well from both sides as boss and patient). Nurses, for whom Thomas has the deepest respect and affection, have taken on the task of compassion and personal care that once extended through all medical personnel. In modern hospitals, he notes sardonically, you get greatest individual attention while discussing your insurance coverage in the admitting office and never so much again on the wards (I can also affirm this from personal experience). The awesome and effective machinery of modern medicine seems to place an unsurmountable barrier between doctor and patient. Old Dr. Thomas would stand in amazement before the advances of modern medicine, but would simply not comprehend the loss of personal contact.

Can anything be done to reinsinuate this sense of active compassion into medical care at all levels? Such an accomplishment would not merely be pleasant; it would be positively therapeutic, since states of mind can influence the course of nearly any disease (as Thomas with his expertise in immunology and the body’s own defenses continually emphasizes in his book), Thomas acknowledges, of course—and this is the ultimate irony—that faced with the choice between his dad’s knowledge of your dog’s name and the most heartless mechanism of a modern hospital, any patient would choose the latter—for getting well is still the primary desideratum in seeking medical care. But is there no way to have both?

Probably not as a statistical phenomenon, for institutions and machinery create personalities and impose the fragmented and limited contact that most medical people now have with their patients. But if medicine attracted more rational humanists, then a force of strong personal commitment might just balance or even overcome the shaping role of institutions. Thomas himself is the prototype of such a man, a medical administrator (the stereotypical role for the heartless) who exudes in his writing and exemplifies by his life all the old-fashioned traits of care and compassion that we must try again to bring into prominence. Perhaps it must be done by example, and we will find no better case study than this very book. Thus, though Thomas did not write The Youngest Science to toot his horn—for he seems the very embodiment of a genuine modesty that does not deny skill and accomplishment, yet refuses to use it for oneupmanship—its ultimate message loudly proclaims that what medicine needs most badly is an army of Lewis Thomas clones.