My Friend David And I Have Gotten Old

I called my stepdaughter Sara on my way down to the Peninsula to see David. She asked me if I had any feelings, any hesitations about going down to see him, as I started over the Dumbarton Bridge. It was a clear day after all the days of rain coming from the “atmospheric river” from Alaska, I guess. Clear, but cold. No, I said, no feelings, but you know I don't anticipate feelings much, I just get them when I get there. I'm really good at denial, and really bad at planning.

Yes, she agreed.

Denial is what gets us through life, I said. People shouldn't knock it.

It was yesterday that David and I walked down in the evening from my freshman dorm at Harvard, the newly converted apartment house called Pennypacker, over Mass Ave and down to Elsie's for a roast beef sandwich. We sang as we crossed the street. It was still September, I think, maybe early October. We hadn't known each other until about a day or two before we left Philadelphia for Cambridge. David had been at Episcopal Academy right on City Line, the very same institution that years later would spring John Yu upon the world, but these days it's pretty clear that you can't blame institutions for the dreck they produce – look at Tom Cotton, for instance.

David was a little taller than I was, with the most open, even wide-eyed open and welcoming face you could imagine on a WASP, which he most certainly was, and that wasn't helped by Episcopal, from the stories he told fondly, but which I received with hesitancy. He prized the faux-English-isms of his teachers. “I dread the day they raise teachers' salaries,” said one, “then every damn fool in Christiandom will want to be one!” Imagine, “every damn fool in Christiandom.” Episcopal was miles away from Lower Merion High, my alma mater, but at Harvard, we were both Philadelphians, who established a “Philadelphia table” in the freshman commons where we ate, long sturdy wooden tables where Lower Merion and Episcopal ate together, and brought other in our orbit there regularly. “Where do you eat, Al” they would ask a new friend of ours from Cedar Rapids, whom I would visit the next summer for a night as my friend DiGi and I crossed the country and stopped there – imagine the excitement of the families as their new friends from Harvard – well, Digi was from U Michigan but still, it was the new friends from the East – as we rolled in and Al set us up with some of the girls from his class, for the one night we were there. Al, after all, was a denizen of the Philadelphia table.

That night we walked across Mass Ave and we sang. David had a good voice and some musical ability, which formed a great contrast to me, who couldn't and can't carry a tune, much to my chagrin. But, observed David, that's a shame, because he told me that I had a musical soul. I don't know about that. I grew to like jazz, but my my roommate John and the guy from the next room over, Lowell Davidson, taught me the names of the current great ones, Miles and Coltrane and Milt Jackson and the rest, basically so I could impress girls.

I had been to Elsie's a few days before and the guy behind the counter, Smitty, was a toothy black guy who was a genius at making sandwiches with his cleaver in nothing flat while a crowd of students vied for his attention. I said to David, I kinda know Smitty, he's from Philadelphia, actually. Imagine Smitty's excitement and interest as the new freshman class appeared. 17 year old, 18 years old, so wet behind the ears, we must have been something to behold. Well, said David, I guess I know him, too, dismissing my claim. We got there and they weren't too crowded and we got close to the counter and I saw Smitty and said hi and he recognized me and gave me a big grin and said, How are you? How's it going? And David said to an unseen audience, He does know him! His admiration for me was immense – he knows Smitty!

I never stopped loving David. The most open, naive in the best way, sweetest guy you could ever meet, always admiring others, never angling for anything, but a wonderful English student and Shakespeare student and eventually he even had a named professorship at Stanford, where he has lived for probably 45 years or so. I think he went there straight from Harvard and just never left. I can't believe he was anything but loved.

I stayed in touch with David, even when I was in med school and he was in grad school. He looked at me then and said, Learning your craft! I hadn't thought of things that way, but I guess that was true. He had met and married Sue when he was in England, probably Oxford I guess, I'll have to ask her, and he lived in Adams House as Assistant House Master or whatever they were called and he told me, We're into coffee as he poured hot water into the paper cone to drip it into the carafe. I thought, that's not a lot to be into, coffee as your passion?

When he was down at Stanford, he and Sue and Ann and I got together a few times to go to plays, but then we gave it up. We all got along well, but the plays weren't great and I guess it usually takes the women to arrange stuff like that, and David and I weren't quite up to it. Women are supposed to run the social show, right? We did our best, and it was fun when we managed to arrange it.

I started a non-profit effort in medicine and I needed two other guys to be on the board. My friend Bob was one and David was the other. It was just a minor league effort but David thought it was a big deal so he insisted on making the drive to Berkeley to sign the papers and go out to dinner – I guess I should be doing the driving for this, he said. The Center for Responsive Health Policy. It was only a vigorous effort at the beginning, but we did manage to have at least one annual board of directors meeting with emphasis on the dinner. David said, Let's see who's responsible for raising money for this! Mocking the stuffy board member that he pretended to be. That was yesterday, too.

After I got off the Dumbarton Bridge I found the building fine, in Redwood City, a hospice converted from some other building. Nice, clean, painted well, attractive and subtle colors. Sue met me there. She is old and frail, too, very thin, quite deaf, using the app on the phone to present in print what here interlocutors are saying, walking with a cane, but vivacious, and so attentive to David. She has done volunteer church work – Church of England, I presume – all her life. So attentive. Brings mango juice from Trader Joe's. I remembered that was their favorite from when I visited the rehab center in the spring, when he was recovering from a fall. Late in the visit she poured some into his mouth and there was a significant amount that dripped down his beard from the corner of his mouth which I wiped away. It doesn't matter, Sue said. David was sleeping for my whole visit. I think he was zonked on Fentanyl. He gets a new patch every few days, Sue said, you can tell from his groaning that he needs it, and he's much better when he gets it. At the end of the visit I asked the aide how he was eating, and she said he has a good appetite. So I guess he still has some time to go. Sue had warned me that she didn't think he would be with us much longer, is how she put it, when I was arranging my visit by texting with her.

His two kids, both divorced, have wound up living back home with David and Sue, and even thought they recognize the tragedy of that, David has loved having them back. They visit all the time, Sue told me.

So this is where he's going to die. It did hit me, as Sara knew it would but as I insisted in not anticipating. When Ann died four years ago, it was at home, and she had me and all the wonderful aides who came 24 hours for the last few months. She was in her own room where she had slept for fifty years, although now in a hospital bed, which was necessary. That's where she would die. It was the best option available. I imagine that David's is OK, too – lots of professional care, and I'm not sure if he minds that he's in an institution, I don't think so. He's in the memory care unit, and a brief glance at the common room ascertained that, with one lady with her head on a table that she was sitting at when I came and when I left, the young staff at a table in the center as though they were at lunch. Maybe they were, although I didn't notice a lot of food, maybe some.

We could never have imagined this as we crossed Mass Ave going down to see Smitty at Elsie's. Elsie's is gone, of course – I checked last time I was there. I guess David isn't into coffee much anymore – mango juice, now. Plus some other tidbits that Sue thinks are delicious. They obviously have gotten a lot out of sharing little things. I'm in a different world. I'm up and at'em most of the time. I drive out to the Lafayette Reservoir and walk the three miles around it in about an hour, and I'm at the gym several times a week, and today I walked 12,972 steps. I drive two cars, mine and Ann's, Ann's more now because it's lower milage. I live alone. I don't know how I'll die, but my med school classmates, some of them, are making a big deal about how they are handling their transition to institutional living. They speak about it clinically, Karl encourages others that it can really work, but the hesitancies of others remain mostly unstated. So many people are staying where they are, the hesitancies don't need to be said, maybe.

It looks like I'm choosing to die at home, but that's not reasonable. Ann could do it because she had me. I could and maybe will get the same caregivers Ann had to help me, but then that's not really enough. When David and I were in Phllly we planned our move to Cambridge, but that was different. We were on the upswing. I didn't plan then what I would feel and what I would do when I was in Cambridge, and I didn't plan on what I would feel when I came down to Redwood City to see David, and I'm not planning now. The best I can do is clean up everything so the kids have as little to do as possible. Digitalize all the pictures on computer. None of them will be in a position to help me, and I wouldn't want to disturb their lives, that would be unreasonable. What I'm planning is to stay vigorous. I gifted myself a home theater for Christmas, and that has to tell you something. I'm thinking of trips to take – last year's trips were great, and I think I'm due a few more. I made a great friend last year, who has been a lot of fun.

I'm not planning, and I wonder if I'm even preparing. What's the difference between denying and preparing? I think they can work together. I sure don't over-prepare. I don't what to be in a place where when I come in I lower the average age. I keep myself in shape. David is going. My friend Lou is going – I can't even get in touch with him now, something has happened, he has Alzheimer's and is not well cared for. Neither my undergraduaate roommate Arthur nor my first boss in the Public Health Service Don can walk. My lifelong friend and undergraduate roommate John has seen his treasured daughter finally die from her brain tumor, finally, of a brain tumor, and John seems to be recovering from it. Classmates die regularly. Thoughtful alumni associations want to help us plan our wills. I'm lucky I have kids and younger friends. Fucking time doesn't stop.

But last week I settled on a motto, two mottos really. “It's never over until it's over.” That's number one. Number two is, “accelerate into the tape.”

Are they mottos to be proud of, or are they denial?

Fuck it. They're both.

Just because I'm an atheist doesn't mean I shouldn't be able to say, I don't need to plan excessively, God will provide. That even has a public policy equivalent: I'll just muddle through. (Lindblom, professor at Yale, 1959.) I'll muddle through, I'll keep my energy up as best I can, I'll keep up studying because it seems that's what I like to do, I'll keep up talking to friends from all times in my life, from those I knew in kindergarten through those I met last year, and I'll keep trying to come up with good and interesting stuff. I'll keep helping others. I'll have fun! Sports! Walk and work out! Writing! Even travel! Keep posting on social media and emailing with friends! My precious family! Projects to help others and be politically active! Really, I've been so lucky, and still am.

And all through it, I'll also prepare to die. I figure the last months of decline I'll just have to wing it, as Ann used to say, one of her favorite expressions, but before that, I'll get as much stuff taken care of as I can, so that the kids are faced with as little busy work, throwing out work, figuring out what to keep work, disposing work, divving up work, all that horseshit you have to go through when somebody dies especially when you have to sell the house. All that stuff I'll try to do what I can, better take care of it sooner or later, because no matter how much I love to deny and just carry on, I really know that it's just a tactic what I'm doing, and I've been lucky so far, but don't push your luck, as Ann would say, don't push it.

Budd Shenkin

How To Save Primary Care

Lisa Rosenbaum is a Harvard cardiologist and a wonderful writer for the New England Journal of Medicine. I didn't know her, but she was a student of my classmate Lloyd Axelrod, and I talked with her on the phone maybe a year ago as she was walking around Manhattan. I wanted to know if we were related, since my paternal grandmother's name was Rose Rosenbaum. It turned out that probably not – we were the Philadelphia Rosenbaum's, and Lisa was the Portland Oregon Rosenbaum's. And I told her how great her writing is – true! – and I told her some of the things I'm up to with my class vis-a-vis humanistic care. People in authority must get calls like that all the time, and if they aren't from esteemed professors or someone otherwise distinguished, they shrug it off. C'est la vie.

She wrote a really great article in the New England Journal of Medicine earlier this month. (https://www.nejm.org/doi/full/10.1056/NEJMms2510425). What is primary care worth, and what can we do to save it, and should we save it? She bemoans the need to defend primary care and the personal relationships of all doctors with their patients, and the fact that there are no measures for this.

But she kind of ends it there. What to do?

Well, I have ideas, and I've written them in an article that few will read. But even though I'm pretty sure the NEJM won't accept the letter, I was moved to write it. Because, not to hide my light under a basket, I really do know what needs to be done. And here it is. You won't be able to read it in the NEJM, so you might as well read it here.

Lisa Rosenbaum's observations of the vexatious problems of evaluating primary care, and humanistic medicine (HM) in general, are correct. She knows deeply how important it is, and so do patients. If standard measures and endpoints are not revelatory, it is due to the weakness of the measurements, not the unimportance of relationships. As William Bruce Cameron has famously observed, "Not everything that counts can be counted, and not everything that can be counted counts."ⁱ

Humanistic medicine needs to be treated as a corporate goal, just as much as biomedical excellence and fiscal positivity.ⁱⁱ Clinically experienced and social sciences trained physicians need to be in high positions of authority in the corporations that run health care. Part of their burden will be to develop methods to assess the effectiveness of the organization in this sphere. These might not be exact measures, but as Lord Keynes observed, “It is better to be roughly right than precisely wrong.”ⁱⁱⁱ

iCameron WB. Informal Sociology: A Casual Introduction to Sociological Thinking. Random House, 1963.

iiShenkin BN. Open Notes in the Context of Humanistic Medicine, The Journal of Pediartrics: Clinical Practice 2025; 17: 200155

iiiKeynes JM. Origin obscure.

 

Brutally Frank

 

Brutally Frank

It would be kind of funny if someone were named Frank, and he named his blog “Brutally Frank,” but I'd guess that someone already did. Actually, I just checked and yes, there is a “Brutally-Frank.com,” and it describes itself as “Midwest Psychos Since 2002”, and there is a sketch of a white skull on a black background. There is also a band named “Brutally Frank.” https://www.sonicden.com/brutally-frank/. So I'm not exactly plowing virgin fields here, I guess.

But the phrase just sticks with me. “Let me be brutally frank.” Gird yourself! Here it comes! I've been learning French for the past six or seven years, I've become brutally aware of language, and how idiomatic English is, because I've been trying to learn the way the French express themselves, and naturally it means learning idioms, after learning the basic words and the basic phrases and the basic grammar, although “after learning” is really incorrect for me, because even now as I forge my way brutally forward, I'm still gathering the rudiments of French, and understanding in the process how long it took me to learn all I did about English, and realizing that I have forgotten how much had to be done, year after year, to really master it. It's like erasing all your drafts of a paper and seeing only the final result which you take for granted. So “brutally frank” is one of those idioms that sticks. In the French dictionary all I can find is “brutalement franc;” I'll have to ask Charles, my French teacher, if they use it in French the way we do in English.

“Brutally frank” seems to imply that before becoming that, you were politely less than “brutally frank.” Which means that you were expressing yourself consciously not wanting to hurt someone else's feelings, which we all have to learn to do somewhere along the road to maturity, and which some people then learn to shed in certain occasions, at which time they can declare themselves as being “brutally frank.” In a way, it's like fessing up, I guess. Shedding the acquired skin.

What enables you to be brutally frank can be that all of a sudden you disregard your own safety and say exactly what you think no matter what the consequences, which may be, after all, brutal. Being brutally frank seems to imply pain on the recipient of this truth, but the teller of the truth might be likewise on the receiving end of someone being brutally frank right back. Politeness on one side seems to beg politeness on the other, but that can be thwarted. Politically, most Democrats currently act politely and still expect that the other side will respect the convention of mutual politeness, not realizing that it probably won't be reciprocal. “My friends across the aisle” can well be cooperating in a coup that could be, well, brutal, to be brutally frank about it.

So, here's the question: what leads to our being brutally frank? Or, what retards us from being brutally frank all the time? I suppose would could all be brutally frank whenever we don't fear the consequences, or just because we can't help doing it, or is we don't foresee the consequences. If you say you are about to be “brutally frank,” it's clearly a choice, but if you are “brutally frank” all the time, it might be because it's involuntary. People introduce what they are saying with “to tell you the truth,” but that seems just like a cliché and doesn't imply that a punch is about to be landed. Being “brutally frank” is different.

If you're very rich, you can be brutally frank a whole lot because your money is a cushion. Or you might think so. If you're brutally frank to your intimates, however, the consequences might not depend on money (although it can). Everyone likes to be loved, but some may fear it, or some might despair of it, or some might not understand that being loved also depends on how you treat someone, so even the loss of love might not retard some people from being brutally frank. But if you've got enough money, probably no one can totally hurt you economically – if you've been wise enough not to be over-leveraged – so sometimes the very rich can afford to be brutally frank without even thinking about it. Like a king, maybe; they can, too.

If someone depends on you, or if you have some leverage over someone, and you don't care about the feelings toward you of that person, you can afford to be brutally frank. Fuck them, you might think. But of course then you have to live with yourself for being hurtful by being brutally frank. But of course, some brutes don't understand what this even means, or maybe not just brutes, but those who are feeling-impaired, like some people with autism who can't understand the feelings of others. Probably some people whom we think are brutes are really just autistic and we ascribe brutality to them, because it's not that they want to hurt others or don't mind hurting others, it's just that they can't understand hurting others. But some people are just bastards. There are many reasons that some people are habitually brutally frank.

Or maybe you have tried and tried, you have tried to be humane, you have gone over a matter in tender detail, and you are still not getting through. Then you could well introduce your last attempt to get through with the phrase, “to be brutally frank,” and then talk about the matter as baldly as possible. You don't mean to be brutal, you have taken every possible step not to be brutal, but in the end, there is nothing left. Sometimes, you just can't dance around it.

Then there are those who pretend to be brutally frank, because they think it is charming. They can hurt others by it in the process – he might say in the midst of others, “My dear, to be brutally frank, this outfit you're wearing makes you look like an alley cat,” as he stifles his gloating laugh of derision. (I wonder how you say “alley cat” in French? Would they say that or is it simply an English phrase not found in other languages?) Brutally frank can be intentionally brutal and hurtful. In this case, “brutal” does double duty, to the words and to the act of malice.

A bully can be brutally frank; I guess the man in that example was a bully, if the woman then shrank and shriveled instead of kicking him in the balls, as he deserved. Trump is brutally frank that way – those Somalians are garbage, says the invulnerable sadistic Trump, whose insides must be a true garbage heap. Some people take it for authenticity, as it matches there own inside feelings that they have heretofore had to suppress. Our worst angels is Trump's specialty, to be brutally frank.

All of which brings me to mon sujet (throwing in a little French never hurt, I figure, but to be brutally frank, I'm afraid it's just being self-indulgent.) I have a group of Six Old Guys – an appellation of brutal frankness, I guess, that is not at all the way we feel, but in fact that's the way we would be mostly described by the outside world. We're in our seventies and eighties, all completely with it, at least that's what testing would show. We write emails to our group, a lot on sports, and a lot on politics. We are not monolithic, although no one would be a declared Republican in the group. One of us, the youngest, actually, has moved from Democratic to Independent, he says. Another identifies as liberal, but to my mind would probably qualify as liberal Republican, Javits style, if they still existed. One of us is constantly obsessed with the mindlessness of those who don't recognize the wisdom of Modern Monetary Theory, and decries the destructive conformity of the economic and political powers who retard the progress our country could make without these artificially constructed barriers to utilizing our full potential. One of us is against tribal thought, and for instance, sees Gazan children and Israeli children as equivalent and each worthy of our compassion. All of us support the importance of the existence of Israel, one of us (me) is so condemnatory of the current Israeli regime that he jumps up and down condemning them and distrusts anything that comes out of Israel. One of us is reluctant to criticize anything about Israel and even sometimes uses the words Samaria and Judea. One of us thinks Israel was completely right in handling Gaza (at least, that's what I get from him, I could be wrong), but decries the incipient fascism of Netanyahu. Others vary.

The question is this: in our Six Old Guys group, how much are we brutally honest? How well do we know and trust one another? How much need we respect the grounds of sensitivity of one another – don't tread there! And how and when can and should we be brutally honest? And how much does not being brutally honest degrade the level of our connection with one another?

On Israel, we have to be careful, because it is sacred ground for one of us, and feelings will remain deep. I myself feel betrayed as a Jew by the Israeli regime, and I fear that Israel has lost for us the most precious heritage that being Jewish means. I remember when my mother said to me, as she instructed me about the world, I think as we were walking somewhere in West Philadelphia, “We're Jewish.” What did that mean? It took a while to find out. We weren't religious, we didn't belong to a temple, we were informed by my mother of the various forms of fitting into Judaism and degrees of fitting into the non-Jewish world, and how could you be Jewish and not be either religious or observant? It involved a set of values. And each day those values are violated by the Israeli regime that violates those values on behalf of their own understanding of what I means to be Jewish. But another one of us has said in the past that one of his rabbis has said, Jews should not speak ill of other Jews (I may have that wrong.) Of course, I dispute that, and I think pretty much everyone else of our group does, too.

So what do we do? We have come up with our solution, which is to agree to disagree. We try not to harp on it, we don't ignore it, but we don't press too hard although we admit our feelings. Are we brutally honest? We might be brutally honest about our feelings on the matter, as much as we can be, but we restrain ourselves from criticizing each other. We recognize the humanity of each other, and we tread carefully. We let love of each other triumph over the urge to fight. Instead, we will shift the conversation to other matters on which we disagree, such as the value and substance of Draymond Green on the Warriors. We all admit that he is a basketball genius, but some of him hate him as dirty and cruel, and others love him despite his problems with expressing anger. On that matter, we can be brutally frank, I guess, although we restrain ourselves from going deep into each others psyche as to why we each feel that way.

Likewise with Bari Weiss. Some of us defend her, others feel she is an awful representative of the weaknesses of humanity. We have had to call a moratorium on the discussion into more evidence comes in that my opponents in the discussion realize the errors of their ways.

Actually, to tell the truth, not saying brutally frank, it all started with an argument over Bob Cousy, some of us declaring him an early basketball genius, others declaring him a talented man made into a giant by various people and forces, the worst being Celtics announcer Johnny Most. The disagreement remains, but does not fester, and discussion of basketball greatness has persisted in our group for years. Occasionally the topic of Cousy reappears, but it seems now an early beacon of how our discussions have evolved. In fact, it is now a running joke with recurrent mirthful calling into question the sanity of the other side. We started in controversy.

We distinguish ourselves as persons as distinct from the opinions we hold. We might try to be brutally frank about issues at hand and to make our cases as trenchantly as possible, but we desist when it comes to each of us personally. We maintain a high ideal with each other, to think the best of each other, and brutal frankness has a place only to be brutally frank in bringing to the attention of others of each other's inherent worth, and the inherent worth of us as a group. Let's be brutally frank, we say in effect, to some extent, for better or for worse, we love each other, or at least we value each other, and recognizing that in brutal frankness is worth the risk of being brutally frank. And the best use of being brutally frank is to bolster the other when they underrate themselves.

Wouldn't it be great if one of us were named "Frank."  It seems to me, anyway.

Budd Shenkin

Testing Blogspot

 I have had terrible trouble with my blogspot!  Then I asked my son to help me.

Interesting - sons help fathers - gift or burden?  It's hard enough when fathers help sons, but what about when it's the other way around?

In the end, we have to be grateful for what God gives us, or chance gives us, or at any rate, what we have. 

Open Notes in the Context of Humanistic Medicine

As readers of Budd's Blog know, I've been very involved in learning about humanistic medicine these last few years. I've learned a lot!

In 1973, David Warner and I were the first to suggest in the literature that patients be routinely given their medical records. Now, a few years later, this is actually being done. An article on how this is being implemented was accepted for publication in the Journal of Pediatrics - Clinical Practice, and the editor, Michael Cabana, asked me to submit a commentary.

Those many years ago when David and I wrote the original article, I couldn't have envisioned the context of humanistic medicine. Now it seems crystal clear. Likewise, those many years ago, I couldn't have imagined the context of corporatized practice, and I would have been hard-pressed to come up with policy recommendations to implement humanistic medicine in that organizational context. Now, that too seems crystal clear.

So, without further ado, here is that commentary, as published in Volume 17, September 2025.Journal of Pediatrics - Clinical Practice.

The Journal of Pediatrics: Clinical Practice

Volume 17, September 2025, 200155

https://www.sciencedirect.com/science/article/pii/S2950541025000171

Commentary

Open Notes in the Context of Humanistic Medicine

Budd N. Shenkin MD, MAPA

Cite

https://doi.org/10.1016/j.jpedcp.2025.200155

Refers to

“Open Notes” in Pediatric Acute Care Cardiology: Caregiver and Provider Experiences in a Single Center

The Journal of Pediatrics: Clinical Practice, Volume 16, June 2025, Pages 200147

Megan Rodts, Dana B. Gal, Brittney K. Hills, Elisa Marcuccio, Colleen M. Pater, Samuel Hanke

Giving patients their medical records was an idea first proposed in the literature over 50 years ago.1 As Rodts et al relate in their article, it took the innovation of the electronic health record to make record sharing practical. Sharing the medical record (SMR) has many objectives, but the major ones are that, by providing transparency into the record, patients will be better able to understand their case, and a frank and trusting clinician-patient relationship will be established in the process. The importance of SMR can best be understood by placing it in the perspective of humanistic medicine (HM) as it has developed over the years.

Medicine has always been a partnership between curing and caring. Curing is the realm of biomedicine (BioM); caring is the realm of (HM). The ultimate objective of HM can be said to have the patient feel known and respected as a person, and to feel cared for and cared about in the medical care process. In the history of HM, the focus has usually been appropriately on the doctor-patient relationship. Peabody's classic 1927 article, The Care of the Patient,2 emphasized knowing the patient personally, with “the material and spiritual forces that bear on his life.” He observed that “the treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.” Szasz and Hollender's 1951 article updated Peabody's view by describing three types of doctor-patient relationships, each appropriate to a different situation: active-passive; guidance-cooperation, and mutual participation.3 As diversity in society became more recognized and the emotional aspect of care further elaborated, later teachers offered more details on the doctor's ideal role. For example, Branch et al noted the importance of “the physician's attitudes and actions that demonstrate interest in and respect for the patient and that address the patient's concerns and values. These generally are related to patients' psychological, social, and spiritual domains.”4 Schattner cited the “Three C's”: “‘comprehension' of the patient's narrative and importantly – emotions; leading to ‘compassion' and a ‘commitment' to act trying to help as much as possible.”5 Other important HM elaborations have also emerged, including narrative medicine, cultural relativity, spiritual comprehension, medical ethics considerations, and end-of-life palliative and hospice care.

Clearly, SMR belongs on the list of developments relevant to HM. While SMR is a general approach, each situation is specific. Rodtz et al outline their initial implementation approach in a highly-technical inpatient ward with highly medically literate patients without special preparation of patients or training of personnel. They found, as others have, that while the initial experience is generally positive, patient acceptance, and even enthusiasm to be part of the team, is easier to achieve than is clinician acceptance.6 Because implementation is always a process, the authors' ideas for further training of medical personnel are sensible next steps.

It is also important to get perspective on how radically different our modern context of HM is, as compared to the past. The geometric expansion of BioM has drastically changed the organization of health care. It is no longer the doctor and the patient simply meeting together in isolation. Medicine now involves innumerable subspecialists and a plethora of new testing, general hospitalist care for inpatients, as well as interdisciplinary team medicine at all levels. Additionally, modern medicine is delivered through very large corporate entities managed by business-oriented leaders, and insurance companies not only pay for care, but often dictate many of the terms of care, including often problematic prior authorizations. Patients are thus now faced with many doctors and other professionals with whom they do not have a continuous relationship, challenges in finding a single source of reliable caring within these complex organizations, threats of getting lost in the system and being treated as a unit of some sort rather than as a known person. In other words, patients now not only interact the known quantity of “their doctor,” they also encounter the unknown through faceless medical organizations, including the residual of organizational complexity.

It stands to reason, then, just as Peabody and the others have urged individual doctors and others to practice HM, we need to urge the organizations themselves to practice HM. The organizations act directly with patients, and can be perceived as attentive and caring or oblivious and bureaucratic. For example, is the phone tree patient-friendly? Is there someone in charge of monitoring the patient's progress at all times, who connects with them on a regular basis? Are appointments easy to make, and above all, timely in serious situations? Does the system enable close collaboration of clinicians, and does it enable primary care providers to easily make out of network referrals if that is in the patient's best interest? The organizations need to take responsibility for their impact on HM. Besides the direct effects that organizations have, they also acutely condition how the clinicians can practice HM. Are clinicians given the organizational support they need so that HM achievements are possible? Are they given enough time per patient? Are they given the necessary tools (in this instance, is SMR supported completely?) Are they given enough helping staff? Do clinicians have easy access to affecting the organization's HM practices and policies? Finally, does the organization provide incentives for HM beyond the clinicians' inherent idealism? Recognition is terribly important.

For the organization to take responsibility, it needs to formally establish HM as a top organizational priority, alongside BioM excellence and financial responsibility. Managers need to be held responsible for measuring and implementing HM in the organization. Budgets need to support HM development, just as budgets always support BioM innovations.

If and when organizations assume HM responsibility, efforts like those of Rodtz et al will be newly empowered. The technological revolution will give them strength – AI may well be able to make medical records understandable to those with different levels of medical sophistication. Language that may be objectionable to patients will be replaced.7 When “the idea that the electronic health record is a self-contained, unitary product (is) abandoned once and for all,”8 additional patient-centered capacities will make tracking patients' progress and helping them constantly a routine capacity. But unlocking the wonders of modern technology to empower HM is dependent on the priorities determined by our current medical organizations.

The good news is that the techniques are close by and obtainable, so that the medical record can be the central element in maintaining HM as a true partner to BioM advances in both caring for patients and curing them. It is simply a matter of priorities. And where there is a will, there is a way.

References

1. 1

B.N. Shenkin, D.C. Warner

Giving the patient his medical record: a proposal to improve the system

N Engl J Med, 289 (1973), pp. 688-692

2,

F.W. Peabody

The care of the patient

JAMA, 88 (1927), pp. 877-882

3,

T.S. Szasz, M.H. Hollender

A contribution to the philosophy of medicine

AMA Arch Intern Med, 97 (1956), pp. 585-592

4.

W.T. Branch, D. Kern, P. Haidet, P. Weissmann, C.F. Gracey, G. Mitchell, et al.

Teaching the human dimensions of care in clinical settings

JAMA, 286 (2001), pp. 1067-1074

5.

A. Schattner

The essence of humanistic medicine

An Int J Med, 113 (2020), pp. 3-4

6.

J. Walker, J.D. Darer, J.G. Elmore, T. Delbanco

The road toward fully transparent medical records

N Engl J Med, 370 (2014), pp. 6-8

7.

I. Toler, L. Grubbs

Listening to tik-tok – patient voices, bias, and the medical record

N Engl J Med, 392 (2025), pp. 422-423

8.

J.E. Harris

An AI enhanced electronic health record could boost primary care productivity

JAMA, 330 (2023), pp. 801-802

Gilles' Story, Madeleine - From The French Novel

As readers of this blog might know, I am taking lessons in French, and as part of my study I prepare a written work each week. So, what I have done in these last years of study is to make each week’s work another chapter in this novel that has yet to have a name attached.

Over time, the characters have become aware of their plight of being characters in a novel, or at least that is what they have come to suspect. As such, they have come to believe that if they are to continue their existence, they had better make sure that they are interesting enough so that the author must continue writing about them. Two new lovers, Léanne and Gilles, have thought that telling interesting stories might be interesting to the author. Léanne told her story (Cendrillon) as recorded here in this blog on July 5, 2025. Now here is the story that Gilles, inspired by Léanne’s story, has come up with. (This is the English translation, of course.)

“It’s my turn, then,” said Gilles.

“Yes. Are you inspired?” said Léanne.

“Yes, maybe. Inspired, or intimidated. Challenged, provoked. Inspired - I prefer that.”

“You are a philosopher, so you have to write. But not just professionally, you have to write your own personal thoughts. All philosophers write, it’s what they do. But we, as characters in the novel, we have to be more personally intimate than traditional professionals. It’s hard to be a character in a novel. We’re not paid enough for what we do!”

She gave a little restrained laugh.

“I ought to deal with obsessional love.”

“I’m not surprised,” she said.

“No?” he replied.

“Right. That’s what I love about you, you’re so fascinating.”

“Not so fast! We need to wait for the result.”

“I’m confident.”

So Gilles related the following story.

Madeleine

Madeleine’s family was quite rich, but the five children were poor in spirit, because their mother, who lacked emotional strength, was not capable of taking care of them. So none of the children knew whether or not they were loved.

Madeleine, the second child and the oldest girl of the flock, always tried to please her mother, but the only way that her mother could express pleasure was by doing nothing, and not complaining. Being an introvert, Madeleine often retreated to her bedroom where she watched television or read her books. She really loved novels, and so in due course she became a very good student of literature. Being of a romantic nature, her favorite book was Wuthering Heights by Emily Brontë, and we can say that this book remained her favorite to the end of her life. For Madeleine, books were always very powerful.

When she was in high school, Madeleine started to feel the desires of the body - that is to say, sexual desires — like all adolescents. Simone de Beauvoir, for example, described how extreme her desire was at the age of 14, to have a man in bed with her. Only sleep gave her relief. That must be the case with most teenagers, and probably of anyone at any age, one might say. In our society there is a great imbalance between the great sexual desire of teenagers and the ability to quench that thirst, and Madeleine was simply another victim of this imbalance. But fortunately, she was weak in mathematics, and so her parents hired a student at the university to tutor her in math after school. Soon she found a way to slake her sexual thirst with this young man.

After her high school years, she moved to a city in the north of her state for college. She didn’t know if her high school tutor was her Heathcliff of her favorite book, but soon she met many other young men, and she said goodbye to the tutor and hello to several of them. She would have been happy to continue her quest for her ideal husband for years, probably, but she couldn’t stop hearing the voice of her mother in her ears. Since she was a mother with old-fashioned ideas, she insisted that Madeleine find a husband as soon as possible. She thought that that was her main responsibility as a mother, to make sure that her daughters marry. Since Madeleine wanted to please her mother, she married her current boyfriend, a nice young man whom she liked well enough.

Since she had studied literature at college, when she graduated she found a position in a publishing house as assistant editor. The three or four older men who had worked there for ten or 20 years were very nice to her, and they all wanted to have sex with her, as she later recounted. Why not? She was thin, svelte, pretty, and she was 22. She liked that, but nothing really happened, there was just flirting.

Her husband was an engineer with no great enthusiasm about being an employed worker, but they had friends and a good life and soon they had two children, a girl and a boy. She loved them very much, and nothing was more important to her than being a good and nice mother. In other words, not being a mother like her own mother. But since she no longer had a job and stayed home with her two kids, and since she had little opportunity to use her intelligence, she became bored at home. She had a woman friend with whom she started to drink wine every Friday. That was a danger sign. She continued to read books.

Then there was a playgroup. The younger of Madeleine’s children, a son, had a friend who had a father. He could just as well as been called Heathcliff, as far as Madeleine was concerned. In short order they began a relationship and neither one could think about anything else. Without thinking about consequences, she needed him. It was a veritable obsession with her, obsessive love. When she called her mother and told her that she was getting a divorce, her mother replied, “I have a new refrigerator!”

Was it really love in the years that followed? Without doubt, they became the most important people to each other in their lives. They fought, but the most important thing in a marriage is that each one sees the other as the most important person in the world.

They had a baby, a little boy full of character, just like his parents. Madeleine became a lawyer, but she left that profession to work in a small bookshop, which she loved very much, being among books and people who loved books. She drank more. Four of the five children in her family had alcoholism, and she couldn’t avoid it. Maybe it was for that reason, or maybe not, that her husband had an affair. They went to couples therapy. Finally, one day she was sitting on the couch and she turned to her husband and said, if I continue like this, I’m going to die. She enrolled in a residential 30 day program, and she became one of the minority of patient who became definitively sober. After that, she was sober for all the twenty years of life that remained to her.

The couple traveled together a lot. He had a hip replacement and surgery for a pituitary adenoma, and she supported him during these illness, and she never drank. Maybe 12 years into her sobriety, she started to forget things. One year later she was diagnosed with Alzheimer’s Disease. Her husband turned to her and said that, from that moment on, they were going to do what she loved best, which was to take cruises and travel. And that was exactly what they did, up to the time when she had to stay in bed because of the progression of her disease.

She could hardly speak, but her husband sometimes wondered if she considered from time to time if she had succeeded in following the plot of her favorite book, Wuthering Heights. One day, when she could hardly talk, she leaned forward in her bed toward her husband, who had hardly left her side in months, and with great effort she whispered, “Thank you, I couldn’t have done all this without you.” Then, the next day, she leaned forward agains and said, “I love you.”

Finally, she had gotten the answer to her question, Is there someone who really loves me? And she had discovered that she would never be abandoned.

When Gilles had finished the story, Léanne turned toward him and said, “What a story, Gilles! It has the real sense of reality! Imagination, fear, a plot (our author’s stories don’t have plots!), and an end that is optimistic but tragic. Do you think that the author will like and admire this story?”

“Well, I hope so!” he said. “Who knows? But I hope so.”

And with that, the chapter came to its end. But now, as he read the chapter, the author’s French teacher was moved to write an addendum!

He wrote: In turning the last page of the chapter that she had just read, Léanne exclaimed, “Look at that! Is it you who wrote this addition? The message written in the book said, “My friends, are you sure of being in the process of attracting the author? Wouldn’t he be conveying, through you, his most intimate secrets? And, is this a banal story, the product of chance? Why now?” Signed: Your faithful reader.

My dream - lost in airport department store

I have planned a trip, and I will have plenty of time to get to the airport. I am at the airport parking structure, and I have to go round and round up the ramp. We get to a spot where some of the cars ahead are going straight, but a couple of the cars are peeling off to the left, and I know that's the way I should go, too. I edge that way, have to avoid a pedestrian or two, and proceed.

As I go farther, I see that instead of finding parking spots, there are lots of shoppers there. I proceed, looking for a place to park, but now I'm the only car, and I'm driving in what looks like a huge department store, with wide ramps that will accommodate both the car and shoppers. I round a corner and choose to go right, down a wide ramp, but now I'm in with shoppers and counters and I can hardly proceed. I choose the leave the car there, and get out and try to find where I should go on foot, scouting ahead, and maybe I'll find someone to ask. I find a young woman, nice looking, dark haired, a little confused, so I ask her how I get to the airport parking lot, but she is just confused.

I move on. I ask someone else who can't help. Finally, I find a woman of a certain age, gray haired, well put together, a pro who knows this place. I tell her my problem, I need to find a parking space, by now I'm not even sure where I left the car, and I have tickets, but even though I left home with plenty of time, with all the delays time is getting short. I get down on my knees and blubber a bit, I'm going to miss my flight! She consoles me and says, it's only $500. I say, more like $5,000. But she is taking on this problem like the pro she is, she's been here a long time, knows every nook and cranny and every situation, and solving problems is her business. She leads me to another nearby department and put the problem to another older woman, also a pro at the store, someone who completely knows her way around. They converse, then I set off following my guide.

We come to a service elevator, or rather two service elevators side by side. We go to the one on the right side. Then the left side elevator comes and opens its door, and my guide keeps that door open and fiddles with some mechanical stuff on the side of the elevator closest to the right sided elevator. I step forward to the right sided elevator and I see that the door is open, but there is no elevator there, and I look down the shaft. It's a long way down.

I step back and think, this is getting dangerous. I'd better wake up. So I do.