The Measure of Our Days: A Spiritual Exploration of Illness
Diagnosis and treatment have always been two of the major elements of medical practice, but with the introduction of the CAT scan and other sophisticated imaging techniques, diagnosis by the laying on of hands began to lose its position as the leading challenge to clinicians. Moreover, treatment has also become much less demanding. Without denying the primacy of judgment and skill in choosing the right therapeutic option or performing a complex surgical maneuver, I believe that the most challenging aspect of medical care now lies in the obligation of physicians to form sympathetic bonds with their patients. By improving diagnosis and therapy, science and technology have facilitated good doctor-patient relationships in certain ways -- it is far easier for a physician to prescribe a cure than to deliver news of an incurable disease. But science is only of limited help to physicians in forming humane attachments with their patients. Trust, empathy, and benevolence are far too complex for scientific analysis. If kindness and altruism mystify poets, how can we hope that molecular biologists will ever clone love and friendship genes?The Measure of Our Days tells us about Jerome Groopman's way with patients, not directly, but through stories -- the way the Bible, with its stories, grapples with the ineluctable dilemmas of living and dying. Indeed, Groopman takes his title from a Psalm of David, Psalm 39, "Lord, make me to know mine end, and the measure of my days, what it is; that I may know how frail I am." Perhaps coincidentally, the preceding Psalm, in which David petitions God for compassion, underscores Groopman's thesis. Groopman's stories recount how he follows the injunction to have regard for those without hope. He hugs them, holds their hands, meditates with them, and shares their tears.Groopman, a hematologist and oncologist with a special interest in AIDS, chronicles the lives and deaths of four patients with AIDS, a man with renal-cell carcinoma, a woman with breast cancer, another with myelofibrosis, and a man who was successfully treated for a lymphoma, only to have acute leukemia develop. There is the boy who underwent successful therapy for acute myeloblastic leukemia, but died of AIDS contracted from a blood transfusion; the physician with hemophilia, a research fellow in Groopman's own laboratory, who had been infected with the human immunodeficiency virus (HIV) by contaminated factor VIII concentrates; the Yankee matriarch with myelofibrosis who on her first visit tells Groopman, "Well, we say in Boston that the mayor should be Irish, the barber Italian, and the doctor a Jew"; and the young woman with metastatic breast cancer who refuses medical treatment in favor of Tao healing. All she would accept from Groopman was morphine. These are not everyday cases. Some might say they are too esoteric, too specialized for general readers. On the contrary, their appeal is wide, because each tragic account illuminates the regard of patients and physicians for each other and how they conduct themselves under terrifying circumstances. They are contemporary medical metaphors of Job, who asked, "What is my strength, that I should hope? And what is mine end, that I should prolong my life?"I don't know whether these stories happened exactly as told -- a proposition that would require Groopman to remember, word for word, numerous conversations he had with his patients. There are very many dialogues surrounded by quotation marks, but the book does not discuss their authenticity. My impression is that The Measure of Our Days, like Truman Capote's In Cold Blood, is a reconstruction of actual events. But this point is of no grave moment, because Groopman's book is more than a collection of moving stories about sick people.Perhaps without intending it, The Measure of Our Days raises important questions about the future of medicine. One problem it presents is where future Groopmans will come from. Surely we will not run out of compassionate physicians, but I worry about a very particular kind of physician who is not only an excellent clinician and wonderful teacher, but also a gifted research scientist. Physicians with this triple combination of talents have always been in short supply, but now, sadly, they are very scarce. This state of affairs is due only in part to tightened financial circumstances. Its causes also include the ever-longer training of physicians who want to learn both a medical specialty and the latest molecular-research techniques; close-minded attitudes about the value of curiosity and scholarship to medicine; and the displacement of professionalism by craft and deal-making. In some academic medical centers, research is not just uneconomic but unpopular. Research physicians, it is claimed, are not pulling their weight in the clinic -- they are an extravagance. These are legitimate reasons for anxiety about the vanishing breed of Groopmans who can embrace a patient dying of AIDS and with equal assurance grapple with complex molecular experiments. Members of learned bodies have recognized the problem and are calling for help, but they are not realistically examining their own positions and the encrusted ways of their institutions. Recent travels to London, Brussels, Paris, and Geneva convinced me that the growing scarcity of "triple-threat" academic physicians is widespread.Some contend that others can do biomedical research better than physicians. Besides, just leaf through the back pages of Science, where plenty of biotech companies advertise positions. All you need to qualify for a job in research on Alzheimer's disease is a bachelor's degree, and lots of companies are looking for Ph.D.s to lead research programs on diabetes. Perhaps this makes bureaucratic sense, but in an illuminating analysis, Flowers and Melmon ("Clinical Investigators as Critical Determinants in Pharmaceutical Innovation," Nature Medicine 1997;3:136-43) clearly show that clinicians make valuable contributions to drug development. They argue convincingly that the participation of physicians who actually deal with the sick substantially accelerates progress in medical research.The Measure of Our Days raises another cause for concern -- time. Time for talking, hand holding, reassurance, and grieving with the sick and their families. Somehow, Groopman found time for all these acts of sympathy despite the responsibilities of supervising a large research laboratory, applying for grants, and writing research papers. But what about physicians who are not academic research stars, those who are deeply committed to full-time clinical practice? For many of them, medicine has been taken over by administrators who watch the clock, measure productivity, and have no way of entering compassion into their balance sheets. Will the 10 or 15 minutes allotted for a follow-up visit permit acts of kindness, or the exchange of verbal trivia that binds the healer and the sick? Will there be time for a hug? The Measure of Our Days is not just stories about how one doctor deals with extraordinary suffering. It challenges the advocates of flow chart medicine to return to the roots of techne iatriche -- the healing science of Asclepius and Hippocrates in which the personal relationship is essential for the restoration of health.Reviewed by Robert S. Schwartz, M.D.Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.--This text refers to an out of print or unavailable edition of this title.