*Adapted from an article published in Journal of the American Institute of Homeopathy 89:74, Winter 1996.
My fundamental beliefs and attitudes about doctoring grew out of my experiences as a student in the 1960’s, long before there was such a thing as “holistic medicine.” Practical dilemmas first encountered on the wards of a large city hospital led me to study philosophy before going into practice, and have continued to shape my career ever since, throughout *internship and more than forty years of clinical work.
In my school days I felt no particular calling to heal the sick, and there has never been another physician in my family as far as I know. Studious and scholarly by nature, I would undoubtedly have felt more at home in an academic discipline like history or philosophy than a worldly career such as medicine. Nor have I ever wholly overcome an instinctive distaste for the actual stigmata of illness, by which I mean not only physical and emotional suffering, but perhaps even more the tyranny they impose on loved ones and caregivers alike.
Why I chose a profession for which I had so little natural inclination, ambition, or special aptitude, and why I persevered in it despite repeated failures and disappointments, thus defines a mystery, and suggests powerful unconscious forces at work. Framing the question in this way takes me back to my grandfather’s death from renal failure around my sixth birthday, when intimations of mortality turned my life upside down. One night as I lay in bed, unable to sleep, my thoughts and fantasies coalesced into a vision of absolute clarity that I too was destined to die, a fate from which no earthly power could save me. At my wits’ end and desperate for solace, I burst into my parents’ room, quite sure that I wasn’t dreaming, and indeed awake as never before from the knowledge that death was certain, a standard of truth utterly new to my experience. From their bland dismissals and obvious reluctance to discuss it, I gathered that death was a mystery I would have to fathom by myself.
Born with a crossed eye that resisted correction with glasses and orthoptic exercises, at thirteen I underwent corrective surgery that left me with a divergent squint both obvious and permanent. Equally powerless to achieve binocular vision or to stop trying to achieve it, I have never wholly adjusted to the resulting headaches, eyestrain, and distrust of “experts,” specialists, and high‐tech solutions that have nevertheless become almost second nature to me.
During the summer after my junior year at Harvard, while employed as a research trainee in biochemistry, I received a wake‐up call that could and perhaps should have ended my medical career before it started. Justly famed for its pioneering work in animal genetics, the Jackson Laboratory where I worked derived the bulk of its income from breeding and exporting pure strains of mice, rats, dogs, cats, monkeys, rabbits, and other species for biomedical experimentation all over the world. Extrapolating from the modest number of animals sacrificed in my own work, as well as that of my mentors and colleagues, I conjured up a rough estimate of the vastly larger total that we supplied to others for similar purposes, and thus came to appreciate the enormity of this terrible enterprise and my own undeniable complicity in it. Since then, no argument however subtle or forceful has ever persuaded me that human progress requires the systematic torture and killing of helpless creatures on such a scale and for such a purpose, or that valid standards of science or ethics could ever be built on such foundations.
In spite of these misgivings, I entered New York University Medical School in the fall of 1959, right on schedule. Most of our clinical work was performed at Bellevue Hospital on the East side of Manhattan, a venerable but antiquated institution that provided the most advanced diagnostic and treatment facilities gratis to anyone who needed them, along with substantial quotas of neglect and abuse from overworked interns and residents, and attentions both welcome and unwelcome from the students as we rotated through each service.
In those days, medical students were initiated into the mysteries of patient care by
“drawing the bloods” for the day, a ritual happily long since dispensed with in most places. In charity hospitals maintained at public expense, indigent patients were routinely taken advantage of by us and the house staff in exchange for their care, and were expected to surrender unlimited quantities of blood for any tests that any of us were even remotely curious about. Even today, more than thirty years later, I can still almost hear the low, mournful wail that greeted us every morning, as the patients saw us coming with our implements down the hall. After days or weeks of experimentation on veins often weak and traumatized to begin with, our last resort was the dreaded femoral puncture, which took only a few seconds to execute, but left both victim and perpetrator holding our breaths until the huge syringes were filled at last.
Accustomed to thinking of illness as a particular episode or life experience that we come down with, work through, and eventually recover or possibly die from, I was wholly unprepared for a reality in which disease was the underlying or default condition, and a vast nexus of goods and services had been created to manipulate and exploit it. On those rare occasions when the beds were empty and the wards deserted, I could still almost smell the ineradicable miasma that lingered in the air, like the accumulated residuum of all diseases past and present. One of my favorite assignments was night call on the maternity service, where the miracle of birth occasionally squirted out before anybody had the chance to interfere with it. Listening to the chorus of women in labor from my cot in the next room, I often reflected on the word “obstetrics,” derived from the Latin preposition ob, meaning “against” or “in the way of,” and the root stet, meaning “stand” or “standing:” an obstetrician, etymologically speaking, was evidently a physician named and indeed celebrated for standing in the way of the birth process, for manipulating and controlling it for doubtlessworthy purposes of our own.
On the medical wards, we were responsible for admitting all lobar pneumonia patients, usually alcoholics from the Bowery, for whom a high fever, productive cough, pleuritic pain, or some equally serious ailment was their only ticket to a warm bed and regular food on cold winter nights. In most cases, the sputum was loaded with Streptococcus pneumoniæ, an organism easily detected by microscopic examination and in those days wholly curable with minute doses of penicillin. Before initiating treatment, however, we were required to inoculate the specimen into the peritoneal cavities of two mice, which yielded an almost pure culture of the pneumococci when we sacrificed them two days later. Since the test was largely academic, I only pretended to do it, not daring to raise the issue of animal testing, but unwilling to witness the atrocity myself.
Routinely enlisting us to perform their dirty work, the house staff merely pointed out that we could similarly lord it over our own crop of students when their turn came. In this fraternal spirit an intern once hit on me to pass a Rehfuss tube into the duodenum of a petite Puerto Rican woman whom he was working up for possible pancreatic disease. Basically a stomach tube tipped with a weighted metal ball to carry it through the pylorus into the small intestine, this little devil was practically impossible for an unanesthetized person to swallow without gagging. After three failed attempts, I found myself wishing that doctors be given a taste of their own medicine before being allowed to administer it to others. When the intern finally took over, he fared no better, and so proceeded to blame the victim, unleashing a torrent of abuse that included racist slurs like “stupid” and “animal” that required no translation. Pulling herself up in bed to her full height, this little lady suddenly and improbably grew in bearing and stature before my eyes, proudly rebuking his insolence, and vowing retribution if he ever molested her again. Not long after that, spotting two burly, mustachioed young Latinos lurking about the ward, I made myself scarce, but inwardly wished them well.
In like manner, the hospital dramatized the need for patient empowerment in the gnarled and twisted shapes it often assumed there, like the middle‐aged black man with a chip on his shoulder who lived on the street, but knew more about emphysema and chronic lung disease than most of the doctors treating him for it, and could usually be found in the library boning up for our discussion of him on rounds the next morning. It took me a bit longer to understand that the inequality in rank and power that allowed us to do whatever we wanted and compelled our patients to obey and even thank us for it culminates in the actual propagation of disease, both indirectly, by spreading fear and doubt, and directly, through excessive use of diagnostic and treatment procedures with obvious power to harm.
One such example followed from the belief of a senior Professor of Surgery that the cause of chronic pancreatitis was spasm of the sphincter of Oddi, by producing reflux of bile into the pancreas, and hence chemical inflammation of the gland. After successfully creating a facsimile of the disease in experimental animals by applying electrical stimulation to the sphincter and clamping off the common bile duct behind it, he developed a protocol for human subjects that blithely crossed the frontier of ethical restraint into a gray zone where the only law was whatever the traffic would bear and whatever a tenured Professor could get away with.
Under his tutelage, Residents at the Surgical Clinic would select a quota of indigent patients with various digestive symptoms for “pancreatic studies,” provided they were not yet diagnosed or claimed for other projects, like the Puerto Rican lady described above. Those who survived the ordeal of the Rehfuss tube might then become eligible for surgical insertion of a T‐shaped catheter into the common bile duct, through which samples of bile and pancreatic juice could be taken for analysis, and radio‐opaque dyes introduced for X‐ray close‐ups of the biliary and pancreatic duct systems, leading in some cases to cutting open the sphincter if it actually proved to be spastic. While I like many others was slow to put it all together, it should not have been a surprise to anyone that traumatizing these highly delicate structures would often irritate and inflame them, thus provoking spasm of the sphincter, and eventually chronic pancreatitis as well. In this stepwise and almost imperceptible fashion, his careful methodology not only confirmed the theory that had inspired it, but also provided a continuous supply of experimental material, since once scarring had occurred, it usually proved irreversible.
Another memorable example of those years was the work of a well‐known pediatrician, already celebrated for his work with the virus of infectious hepatitis, now known as Hepatitis A, who conclusively proved for the first time what many had long suspected, that the disease is transmitted by mouth, through ingestion of contaminated feces, just like polio and other intestinal viruses. He too succeeded by his willingness to conduct dangerous experiments on individuals without their consent, in this case retarded children at Willowbrook State School, who could not speak for themselves and often lacked parents or guardians who were willing or able to speak for them.
Feeding stool samples from those with known infection to other inmates not yet sick, this doubtless sincere and even dedicated physician soon had irrefutable data regarding the portal of entry, incubation period, clinical course, liver enzymes, and every other known parameter of this major infectious disease. Some years later, when a citizens’ group tried to blow the whistle on his research, which was conducted largely at public expense, he correctly pointed out that the disease was rampant at the school in any case, because of overcrowding and poor sanitation, and was allowed to continue his work without interruption or even a reprimand.
Neither man was intentionally cruel or malicious, in the manner of serial killers who defy social norms, or torturers and war criminals who carry out atrocities or give in to coercion or social pressure under extreme circumstances. What they did was evil and indeed monstrous for precisely the opposite reason, that they were successful and even illustrious in a system which prizes their work so highly and rewards its achievements so richly that the distinction between valid science and criminal or immoral behavior is far less clear and the legal and moral standards regulating it are correspondingly ambiguous.
By my fourth year, as “matching day” for internships drew near, I realized that I could not bring myself to practice medicine in the way I’d been trained, and accepted a graduate fellowship in philosophy at the University of Colorado, in large part to try to find clarity and meaning in what I had just lived through. Long before I found words to articulate or concepts to explain it, I “knew” on some deeper level that reducing illness to “diseases” and abnormalities and using drugs and surgery to separate or remove them from the patient’s body are always fraught with ethical and practical risks that I could not accept on a routine basis, or simply because that was how things were done.
Finally, in 1966, three years later, I served a one‐year internship at St. Anthony’s Hospital in Denver, including rotations of three months each in Medicine and Surgery, and two months in Pediatrics, Women’s Health, and Emergency Medicine. With well over 500 beds and no Residents or permanent clinical Faculty, it was not designed or run as a teaching institution. Our instructors were simply the Attending Physicians using the hospital to admit and care for their private patients, on whose behalf we might be asked to complete an admission workup, insert an IV or venous cutdown, assist in surgery, or carry out any other menial tasks the Attending or Nursing Staff might require. In addition, indigent patients referred in from the ER or Outpatient Clinics, which we also staffed and ran, were assigned to our personal care under the nominal supervision of our Preceptor for each service.
In short, we operated for the most part under the old apprenticeship system, which grounded me thoroughly in how medicine was actually practiced, allowed me to learn at my own pace, and left ample room for close personal relationships with supervisors, attendings, nurses, and patients alike.But while generally knowledgeable and helpful if we could find them, our preceptors were often too busy with their own patients to be available when we most needed them. With only eight of us to cover the whole place, we were usually on our own, often in the dark, and wont to proclaim as a virtue the “see‐one, do‐one, teach‐one” philosophy we were obliged to live by. While our patients undoubtedly appreciated and often benefited from our personal attention, they paid for it many times over by having to run the gauntlet of inferior care that followed from our having to learn everything pretty much by the seat of our pants.
In a typical vignette, my first D & C was ordered by my OB/GYN Supervisor for “diagnostic purposes,” in a Welfare patient with a history of excessive vaginal bleeding. Since the Hospital was owned by the Catholic Archdiocese and closely supervised by nuns, I was surprised when he told me not to bother with a pregnancy test, but I didn’t argue. In the Operating Room, he took all the time in the world to show me how to administer paracervical anesthesia, dilate the cervix, and curette out the endometrial lining, but then grew oddly impatient during the procedure itself. “Moskowitz, get finished, already!” he kept barking at me, seemingly heedless of the fact that I was still removing handfuls of tissue, with no trace of the harsh, grating sound he had just taught me to wait for as the endpoint of the procedure. Once again I obeyed, but the Pathology report confirmed a pregnancy, and the next day we had to take her back and finish the job. Although he continued ever after to deny any prior knowledge or suspicion of it, both the illegality of abortion in those days and the woman’s profound gratitude for what had happened pointed to our flawed collaboration as just about the only way for her to get the help she needed. Far more than any technical information, these were the lessons that stuck.
Another memorable experience grew out of my friendship with a patient, a Hispanic guy in his mid‐forties who had developed chronic thrombophlebitis of the deep veins of the calf as a result of the surgical ligation and stripping of his unsightly varicosities that he had been so eager for a year or two before. I have yet to hear a convincing rationale for this purely cosmetic procedure, which by removing the superficial veins effectively doubles the load on the deep system, itself already compromised in many cases, and thus often brings about the same kind of chronic venous insufficiency that had more or less crippled this man with little hope of relief.
In time we became friends, and one day he invited me to his home in the projects to meet his wife, sample her famous enchiladas, and stay the night. In the wee hours of the morning, he woke me with an urgent plea to examine his aged father, who lived across the courtyard and was complaining of severe chest pain. As I entered his room, the old man was sitting up in bed, leaning forward with his hands clasped over his heart and a look of mortal terror in his eyes, a textbook picture of acute myocardial infarction.
Though equipped with nothing but my little black bag, and understandably reluctant to treat him at home, I dreaded even more subjecting him to the quasi‐military atmosphere of the ambulance and Emergency Room, where his inability to speak or understand English made the risk of a serious or fatal complication loom even greater. So I gave him a shot of morphine, and within minutes he fell into a deep and peaceful sleep. By the time I left for work several hours later, he was resting comfortably in bed, obviously feeling much better, at which point his wife told me that he had recovered from at least three such episodes in the past, without any drugs or medical attention whatsoever. That made me wonder whether a lot of patients might not heal better at home, not only from heart attacks, but many other serious ailments as well.
As in most hospitals, the bulk of our instruction actually came from the nurses, who basically ran the place, but knew how to make it look as if they were following our orders, rather than the other way around. Thus on a typical night in the ER, if a patient came in, say, wheezing from an allergic reaction, some version of the following dialogue would most likely ensue:
Nurse: Shall I get the Benadryl, Doctor?
Doctor: Yes, thank you . . .
Nurse: How much, Doctor, maybe 50 mg. IM?
Doctor: Yes, that sounds about right . . .
Along with much practical information of this type, we also learned from the nurses how to “play doctor,” to enact the part of a physician in society, including roughly equal parts of bedside manner, educating the patient, and simply “breaking the news.” Once I tried in vain to revive a 49‐year‐old man who had suffered a massive coronary in a Hospital corridor while awaiting elective surgery for a minor problem. With no idea of what had happened, his wife walked in just as he was being carted off to the morgue. Asking what the ice was for, she was told matter‐of‐factly, “We always pack ’em like that when they expire,” her hysterical shrieks and sobs leaving me to grope for what few words of comfort I could come up with. From then on, the nurses often called me at such times, simply because I would take the time
to speak with the relatives and make sure that they too were cared for.
Much as I enjoyed the thrill of performing surgery, and admired the technical skill and ingenuity that made it possible, at 6 in the morning it was always a challenge to get down enough breakfast to avoid feeling faint or nauseous at some point during the gastric resection or hysterectomy I was about to scrub in for. Although certainly in favor of chemical intervention and reconstructive or emergency surgery in acute or life‐threatening situations, I already distrusted long‐term drug treatment in most instances, and avoided elective surgery wherever possible, regarding them as a last resort rather than the model for what we were supposed to be doing. But they were still all I knew. Had anyone brought up acupuncture, homeopathy, or anything equally outlandish at the time, I’m sure I wouldn’t have been in the least interested in or hospitable to it.
After completing my internship and licensure, I took my first job, a locum tenenscovering for a busy GP who was taking a long‐overdue vacation and had left strict instructions to his patients not to come in unless their problems wouldn’t wait until he returned. Even so, I worked harder during those four weeks than at any comparable period before or since, beginning with Hospital rounds at 7 a.m., then office visits virtually non‐stop until 9 or 10 at night, averaging at least 50 patients a day, 6 days a week, a schedule by no means unusual for a busy GP then or now. On top of that, I officiated at eight births, and covered the Emergency Room one night a week, when I could expect to be up into the wee hours admitting, working up, and following new patients without established physicians of their own.
On one such night, the ambulance brought in a heavy‐set, 45‐year‐old Polish lady who spoke not a word of English and limped in bent over, holding her back, and groaning in pain. Suspecting a kidney stone, I palpated her abdomen and was surprised to find her far along in a pregnancy of which she herself was unaware. From her husband’s very rough translations, I learned that she had never been pregnant before, had had no period for 9 or 10 months, and simply let it go at that, not feeling or suspecting anything out of the ordinary, assuming she was menopausal, refusing to believe her husband when he told her the news, and flying off the handle at both of us for making a joke at her expense. When a vaginal exam revealed that she was also in advanced labor, I rushed her to the delivery room just in time to hand her a nine‐pound baby girl who seemed perfectly normal in every way. Back in the nursery, however, she regurgitated whatever she drank, and a Barium Swallow and Upper GI revealed a tracheo‐esophageal fistula that had to be repaired without delay. Both mother and child went home in fine shape in less than a week, but the greater part of this saga occupied just a few hours in the eventful life of my absent employer, whose seven‐league boots I was struggling mightily to fill.
When he returned, I became House Physician at the Beth Israel, a smaller hospital nearby, where my duties were much the same as during my internship, doing chores and little favors for the nurses, the Attending Staff, and their patients, as well as assisting in surgery, being on call for any emergencies or special needs, and supervising the Old Folks’ Home out back. Always a favorite part of my practice, working with the elderly demands mainly personal care and attention, with little expectation of radical cure, yet earns profound gratitude for any relief of pain, suffering, or the accumulated burdens of survivorship.
At the same time, I moved back to Boulder and began seeing patients in my little ground‐floor apartment, mostly students, friends, and street people, as an experiment to make my practice more open, informal, and as consensual as possible. My procedure was to examine them as noninvasively as the situation allowed, using only the simplest tools, with as much give‐and‐take and direct participation as they seemed to want or could handle, making the diagnosis, to be sure, but then putting it “on the shelf,” so to speak, and waiting for their own individual need or history to suggest a regimen and plan of treatment most uniquely suited to them. While often difficult, and by no means uniformly effective, this down‐to‐earth approach was at least “clean,” honest, unlikely to cause harm, and kept me closely attentive to the doctor‐patient relationship at every moment. Ever since then, these same priorities have continued to guide me in my search for a method and style of practice that could pass the test of time.
Meanwhile, as the War in Southeast Asia continued to spread and intensify without letup, I began to realize how thoroughly both my medical training and the culture of illness and disease that we all grow up with are steeped in the imagery of warfare and combat. With drug ads and hospital and charity fund drives all promoting the conventional wisdom that viruses and bacteria are simply invaders to be expelled and diseases enemies to be fought, most people were and indeed still remain ready, willing, and eager to use chemical weapons such as antibiotics, antihypertensives, antimetabolites, and other “magic bullets” against any complaint or abnormality that threatens or merely bothers them. But when an American General openly boasted of destroying a village in order to save it, his words borrowed almost verbatim from the cancer specialist, the gruesome footage of such exploits transformed what had formerly seemed like a mere figure of speech into a systematic philosophy of militarism for its own sake, with a gratuitous ferocity that began to shock even its own proponents. In that way it dawned on me that I’d been trained as a soldier to fight in the front lines of an endless war against disease, armed with the latest weapons to shoot down and kill all symptoms and abnormalities whenever and wherever they showed themselves. Once again, as in medical school, I prayed for the courage and opportunity to desert my post and fight no more.
By then I was practicing what I would call “minimalist” medicine, that is, giving out liberal helpings of education and advice, while doing as little as possible of a drastic nature, seeing my role as mainly guiding people through the medical system and protecting them from being hurt too badly. These are still important priorities for me; but back then, with fewer and fewer procedures available that did no harm and made sense to me in other than acute or extreme circumstances, I had little to offer my patients when their illnesses got worse, while my growing estrangement from the profession as a whole made it increasingly difficult and unpleasant for me to practice at all.