The Elements of Style in Medicine

Abstract

On the occasion of your graduation from Mayo Medical School, I would like to offer some thoughts for your consideration as you continue to develop as physicians. During your years at Mayo, you have learned many things about the science of medicine. You have also had the unique opportunity to observe the art and the ethics of medicine at Mayo Clinic. Today I would like to dwell for a few minutes on what I call the “elements of style” in medicine, which I believe are exemplified at Mayo. In selecting a subject for my remarks, I was influenced by a little book entitled The Elements of Style, written by William Strunk, Jr., in 1918. Professor Strunk was an English teacher at Cornell University, and the original version of his book was a 43-page summation of “the case for cleanliness, accuracy, and brevity in the use of English.”1Strunk Jr, W The Elements of Style. Macmillan Publishing Company, New York1959Google Scholar The elements of style in English usage will always elude me, but I greatly admire the aforementioned book for its vigor and its importance in explaining the language in simple terms. Likewise, consideration of some basic but important elements of style in the art of medicine seemed appropriate for this occasion. Sir William Osler noted that “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Others have defined medicine as an art and a science or as a group of sciences. It is a learned profession whose members are proficient in these sciences and experienced in the practice of this art. Certainly, the practice of any art necessitates a style. Style is important in all aspects of medicine, whether in education, research, or practice. As physicians, we are fortunate to be able to practice both science and art. This dual approach demands the utmost use of our human capabilities. In science, we formulate hypotheses based on observation that lead to diagnoses and possible treatments. This science is learned in medical school. Art, however, is not based on what we have observed directly. By the practice of art itself, we discover what we can say and do. As we learn the art of medicine, we develop a style—a pattern for communicating our feelings and thoughts. The Scottish author Robert Louis Stevenson described a style for all physicians to emulate, although few of us achieve such excellence. Stevenson, by the way, suffered from tuberculosis and consequently saw many physicians. Although I do not believe that his opinion of physicians is particularly valid, I enjoy reading it from time to time because it uplifts me. In the dedication to his volume Underwoods, Stevenson2Stevenson RL Underwoods. Charles Scribner's Sons, New York1895: 91Google Scholar wrote the following: There are men and classes of men that stand above the common herd: the soldier, the sailor, and the shepherd not infrequently; the artist rarely; rarelier still, the clergyman; the physician almost as a rule. He is the flower (such as it is) of our civilisation; and when that stage of man is done with, and only remembered to be marvelled at in history, he will be thought to have shared as little as any in the defects of the period, and most notably exhibited the virtues of the race. Generosity he has, such as is possible to those who practice an art, never to those who drive a trade; discretion, tested by a hundred secrets; tact, tried in a thousand embarrassments; and what are more important, Heraclean cheerfulness and courage. So it is that he brings air and cheer into the sick-room, and often enough, though not as often as he wishes, brings healing. Stevenson was also a lawyer; few lawyers would subscribe to this view of physicians today! My charge to you is to strive to live up to Robert Louis Stevenson's opinion of you and your profession. It will be a difficult task but one that should be pursued worthily. The word “style” has several meanings. For the purposes of this presentation, I will describe style as overall excellence that demonstrates skill and grace in performance, manner, and appearance. In medicine, style should be important in developing relationships with colleagues but even more so in developing relationships with patients. Compassion is the hallmark of a truly fine physician. Persons without a generous allotment of compassion perhaps should be in another profession. Empathy is one component of compassion, but I believe that compassion encompasses more than empathy. The compassion of the physician is the element that bestows the human touch on medical care. The current tendency is to dehumanize medicine, but the truly mature physician will characteristically avoid this dehumanizing process. This premise was expressed by Dr. Solomon Papper in his article, “What Do You Want To Be When You Grow Up?”3Papper S What do you want to be when you grow up?.Forum Med. May 1978; 1: 31-36Google Scholar Growing up, Dr. Papper suggested, takes a long time and involves dedicated pursuit of the concerns for justice, compassion, and respect for scholarship. If physicians strive to achieve these goals, medicine will retain its human integrity. Youngsters are often reminded to be ladies or gentlemen, but the meaning of the word “gentleness” is seldom considered. Eventually, however, most of us realize that the gentle traits in men and women are pleasing and produce primarily positive responses. In those persons who have made positive impressions on us and those whom we admire, gentleness seems to be a common characteristic. Gentleness in all we do and in all we are, in our relationships with other physicians, and certainly in our contacts with patients is an important aspect of the style that most of us would like to emulate in medicine—and indeed in life. In his essay “Aequanimitas,” Sir William Osler4Osler W Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine. P Blakiston, Philadelphia1904Google Scholar described what he considered an important trait. Equanimity is derived from a balanced disposition and an evenness of mind, especially under stress. These traits are valuable in everyone but particularly in physicians caring for the sick. Physicians should deal with each patient with equal regard and compassion, a goal that may be difficult to achieve under trying circumstances. Temperance is an important element in the style of men and women of medicine. Ancient philosophers were concerned with the concept of temperance,5Adler MJ The Great Ideas: A Syntopicon of Great Books of the Western World. No. 3. Encyclopaedia Britannica, Chicago1952: 866-881Google Scholar and the maxim that expressed this philosophy was “nothing overmuch.” Plato and Aristotle always cited courage, justice, and temperance as the fundamentals of virtue. In his essay “Of Moderation,” Montaigne6Montaigne ME Of moderation.in: Hazlitt WC The Essays of Michel Eyquem de Montaigne (Great Books of the Western World, No. 25). Encyclopaedia Britannica, Chicago1952: 89-91Google Scholar described temperance as the measure of the sound pursuit of every sort of good. He further noted that persons who lack temperance can corrupt things that in themselves are good. For example, if virtue is embraced too stringently, it may become vicious or radical. This distortion can be seen in some workaholics who pursue their careers to the exclusion of their families and balanced lives. It also manifests in persons who become fanatics about their strongly held beliefs. In addition to examining Montaigne's view of temperance, I should mention that he did have considerable reservations about the medical practice of his day. He wrote that the ignorance of patients enabled the physician to claim credit for successes and to blame fortune for failures. The increasing knowledge and sophistication of patients today, however, would certainly eliminate Montaigne's worries about such a situation. Highly developed communication skills are vital in all walks of life and in all professions but especially in medicine. The practice of medicine demands that physicians communicate precisely and effectively with patients, associates, and peers, but more is necessary. Physicians must also communicate pleasantly. Communication with patients involves more than mere words. Norman Cousins,7Cousins N The physician as communicator.JAMA. 1982; 248: 587-589Crossref PubMed Scopus (12) Google Scholar who wrote about the physician as a communicator, pointed out the need for the following: There are qualities beyond pure medical competence that patients need and look for in their physicians. They want reassurance. They want to be looked after and not just looked over. They want to be listened to. They want to feel that it makes a difference to the physician, a very big difference, whether they live or die. They want to feel that they are in the physician's thoughts. Honesty is one of the most important building blocks in the characters of men and women of substance. It is so basic that it is almost embarrassing to list it as an element of style in medicine. Dealing with human life in the capacity of a physician demands impeccable honesty. In all relationships, we physicians must conduct ourselves in an irreproachable manner so that not even the slightest question would be posed about our honesty. This quality is the hallmark of our responsibility to patients, to society, to colleagues, to family, and finally, but not least, to ourselves. Included within this element should be the intellectual honesty to admit our lack of knowledge when appropriate. The final element of style in medicine that I will discuss is attention to appearance and behavior. Admittedly, this element may not be as important as the others. Nevertheless, to be effective physicians, we must pay strict attention to our appearance and deportment. Dignity and cheerfulness are important behavioral features for physicians. Whether it is deserved or not, society views medicine as a high calling and has great, perhaps unrealistic, expectations of the medical community and its potential accomplishments. Perhaps because of this perceived elevated status of physicians, society tends to judge them on the basis of personal appearance and behavior. In general, the younger and the less experienced physicians are, the more critical society may be in judging these attributes. New physicians beginning in practice, particularly in a solo practice, may discover that both personal appearance and the appearance of their offices may have an influence on the success of their medical practice. In recent years, new physicians have tended to be less concerned with appearance and behavior, but the competitive forces in medicine today will prompt all of us to reconsider these factors as we evaluate our professional goals. The elements of style in medicine are many and varied. Each of us ultimately will develop and demonstrate characteristics in a combination appropriate to our individual personalities. In his Elements of Style, Professor Strunk attempted to “cut the vast tangle of English rhetoric down to size.” In my “Elements of Style in Medicine,” I attempted to reduce the attributes of the good physician to a few of the most important ones—compassion, gentleness, equanimity, temperance, good communication skills, honesty, and attention to appearance and deportment.