Writing in the Journal of the American Medical Association at the beginning of July, a cardiologist and Professor of Medicine at the University of Colorado School of Medicine, Dr. Lawrence Hergott calls upon his fellow physicians to fight for their profession by fighting for their own souls. "I have seen that the preservation of the soul of medicine is also the preservation of the soul of the physician, and that both are essential," he tells us.
Over the last couple of weeks I've been pointing out Dr. Hergott's JAMA essay, "The View From Fiesole," to a rainbow of physician colleagues. It has evoked a powerful and sympathetic response from elite specialists as well as primary care providers, medical students as well as leaders of academic and corporate medicine.
Dr. Hergott begins his essay with several short anecdotes to illustrate the personal consequences, for physicians, of "external forces" weighing down upon the profession. These forces are imposed, he writes, by "interests largely driven by economics and profit."
In one anecdote the Dean of the medical school asked the entering class of medical students for a show of hands. Dr. Hergott writes:
"Our dean asked the students how many of them had been advised by at least one physician not to go into medicine. Eighty percent of the students raised a hand," he tells us.
Dr. Hergott calls the whole process the "devolution of medicine."
Yet instead of portraying physicians as hapless victims of forces beyond our control, he lays responsibility for the fate of our profession where it most belongs -- with the profession itself, with us.
"Physicians have historically not been sufficiently attentive to the financial implications of health care delivery," explains Dr. Hergott. "This devolution of medicine must be reversed," he implores us, "not just for us, but for the welfare of patients, our loved ones, future physicians, and our culture."
Dr. Hergott seeks to rally his fellow physicians with an elegant metaphor, a trip to Italy. He contrasts "being in Florence" with "the view from Fiesole." In his metaphor Florence represents the everyday life of the practice of medicine, -- hectic, insensitive, and perhaps somewhat dirty. The view from Fiesole represents the place of repose that, properly embraced, reveals to us the truth and beauty, liberty and love of practicing medicine.
"Fiesole is in Tuscany, just a few miles up a hill from Florence," Dr. Hergott explains. "Galileo and many other notables spent time there, including John Milton, who mentioned Fiesole in Paradise Lost." Dr. Hergott goes on to cite a contemporary writer who lists the view from Fiesole among the great muses, alongside Love, alongside Suffering.
Dr. Hergott reminds us that the soul of medicine still contains something pure and beautiful -- a calling to serve humanity. He suggests that even if we must live in Florence we are still capable of the view from Fiesole.
His remarkable short essay employs several anecdotes to contrast Fiesole with Florence in terms of the bedside behavior of physicians. These tight paragraphs should prick everyone's eyes with tears. Here is one of them. Dr. Hergott writes:
"Being in Florence would be admitting to the hospital a patient with chest pain who was quickly diagnosed with metastatic carcinoma so disseminated that a primary source could not be found, having the patient’s care taken over by Oncology, and moving on to the next responsibility. Taking the view from Fiesole would be going to visit the man at the end of work a few days later and, from something he said regarding his feelings about dying, learning what comfort that small gesture of presence brought to a dying man. “I fear death,” he said. “No, I loathe death. I fear being cared for by someone who wouldn’t drop by at 6 o’clock on a Friday evening.”"
As Dr. Hergott sounds an alarm about the future of our profession he seeks to lead us all, as physicians should, by example.
Personally, for me the view from Fiesole conjures E.M. Forster's "A Room With A View." In the great novel, it is on the outing to Fiesole that George suddenly kisses Lucy. But it was the adaptation by Ismail Merchant and James Ivory, with the academy-award-winning screenplay written by Ruth Prawer Jhabvala that long ago made Fiesole something of a genuine muse in my own life.
Memories of watching "A Room With A View" cannot be untangled from the feelings of falling in love with Lori, the woman, friend, lover, companion, muse, with whom I've been now for almost 25 years.
On the trip to Fiesole, in the Merchant-Ivory-Jhabvala film adaptation of the Forster novel, shortly before he kisses Lucy in the spectacular field of violets overlooking Florence, George bellows to the summer cosmos: "Liberty! Truth! Beauty! Love!"
"Could that be the silent, dour George?" one of the party asks.
George's father, replies: "He's saying his creed. He's declaring the eternal Yes."
Dr. Hergott's essay really hits home. For our profession in this moment, Dr. Hergott has declared, in a brief JAMA essay, "the eternal Yes."
Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.
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