EP. 38: ON VISION AND THE ARTS

Nov 23

WITH MICHAEL MARMOR, MD

A leading ophthalmologist shares how he comforts patients with vision loss and discusses the role of the arts in medical education.

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Episode Summary

Few would dispute that vision is just about our most important sense. At least from a neurophysiological perspective, more than half of the human brain is dedicated to processing vision. But it also enables us to meaningfully interact with the world and the people around us, and allows us to engage in many of the activities that bring us joy in life. Joining us in this episode is Dr. Michael Marmor, Professor Emeritus and former chair of ophthalmology at Stanford University School of Medicine. In addition to his significant contributions to our understanding of diseases of the retina, Dr. Marmor is a patron of the arts who has published several books on vision and visual art. Over the course of our conversation, we discuss the fascinating inner workings of eyesight, how art appreciation can help create better doctors, and how Dr. Marmor accompanies patients facing vision loss.

Michael F. Marmor is Professor Emeritus and former Chair of Ophthalmology at Stanford University School of Medicine. The author of numerous peer-reviewed journal articles on the pathophysiology, diagnosis, and treatment of retinal diseases, he has also written pioneering studies on the role of vision and eye disease in art and created visual simulations to demonstrate the effects of visual loss on art, including the late works of Monet and Degas. Dr. Marmor earned his MD from Harvard Medical School and completed his residency at Massachusetts Eye and Ear Infirmary.
In this episode, you will hear about:
• How a desire to “wear multiple hats” — researcher, surgeon, educator — led Dr. Marmor to ophthalmology - 2:04
• A brief exploration of the sense of sight - 4:01
• Dr. Marmor’s research on the retina and why he believes a thorough understanding of how diseases work is critical for physicians caring for patients - 8:07
• Why helping a patient understand their condition provides comfort, even with serious illnesses - 11:53
• Dr. Marmor’s passion for the fine arts and how his expertise in vision complemented this passion - 18:23
• What art appreciation can do for physicians and how it gives us new ways of thinking and seeing - 23:52
• How medical curricula can be improved to integrate the arts and humanities, and the importance of an emphasis on breadth in addition to technical depth - 33:06
• Why an appreciation for all kinds of art keeps us in touch with culture - 46:29
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctors Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions. We meet with deep thinkers, working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Few people would dispute the assertion that vision is just about our most important sense. Certainly, at least from a neurophysiological perspective, more than half of the human brain is dedicated to processing vision. But it also enables us to meaningfully interact with the world and with the people in it, and allows us to engage in many of the activities that bring us the most joy in life. Joining us in this episode is Dr. Michael Marmor, professor emeritus and former chair of ophthalmology at Stanford University. In addition to his significant contributions to our understanding of diseases of the retina, Dr. Marmor is a patron of the arts who has published several books on vision and visual art. Over the course of our conversation, we discussed the fascinating inner workings of eyesight, how art appreciation helps make better doctors, and how Dr. Marmor accompanies patients facing vision loss. Dr. Marmor, thank you so much for joining us and welcome to the show.
Michael Marmor: [00:02:02] My pleasure.
Henry Bair: [00:02:04] So you are the first ophthalmologist we've had on, and it's a special occasion, especially for me, since for listeners who aren't aware, I'm interested in ophthalmology as a medical specialty and in fact currently amid the residency application cycle. Needless to say, I'm looking forward to this conversation very much. Dr. Marmor, can you take us all the way back and tell us what first drew you to ophthalmology?
Michael Marmor: [00:02:31] Well, that's a long story, which I'll try to make short. My dad was a physician. He was a psychiatrist and wanted to get me interested in psychiatry, of course, as all fathers do in their field. But psychiatry back then this was more than half a century ago, was kind of non therapeutic. You basically talk to people and not much more was known. And I was a scientist, I was a neuroscientist trying to be one anyways and understand the brain. So after medical school I decided probably psychiatry was not going to be my field. And I had gone to the NIH and spent three years doing basic basic neurophysiology. But I didn't really want to be only a scientist. I wanted to also see patients and experience personal interactions and do surgery. Neurology was almost as non therapeutic as psychiatry in those days, and neurosurgery still took half your life before you ever got close to a patient. Started thinking what else might work? And I was working on the nervous system and on the brain. The retina in the eye is part of the brain. So I just shifted my my research to the retina, which were nerve cells and brain cells, and found ophthalmology, a field where I could take care of patients, where I could do surgery, where I could be involved with the basic science. And it served all of those needs very well. And I've been very happy, happy at it now for really again, for half a century.
Tyler Johnson: [00:04:01] Michael, one thing I'd like to pause on this might sound like a funny question, but I, I actually think it would be fascinating for our listeners, Who span the gamut, which is to say that some of them are not involved in medicine in any formal way. Some of them are early med students and then we have a lot of trainees and doctors. But of course, even most of the trainees and doctors are not ophthalmologists or I'm sure we have a few, but most are not. Can you just walk us through very briefly sort of the postage stamp version of how sight works? As someone who has devoted your life to studying this, because I think that's one of those things that you get, even if you are a doctor, you get at best probably three or four or five days in medical school, those lectures and then don't have them ever again for many, many years after that. So I think for those who don't know and even for those who once maybe knew for one quiz or exam, but have since forgotten, can you just walk us through very briefly, like how does the eye take light waves from stuff that's happening outside of your body and make it into an intelligible picture that allows you to navigate the world or to be ordered a sunset or whatever?
Michael Marmor: [00:05:07] I'll tell you, this doesn't have much to do with ophthalmology. And Stanford students are lucky to get 4 hours, not four days. But I'll try to give you a little bit of feeling for this. Vision is important. It's what, in a sense, that's most animals have contact with the world. And it sometimes is said that the that the retina is an extension of the brain or an out part of the brain. We like to say it's the other way around. The brain is an outpouring of the eye because animals developed incredible eyes early in evolution, but they didn't have a central nervous system that evolved later. But how does vision work? Vision depends most significantly on the ability to change light into a neural signal. And that's what the photoreceptor cells in the retina do because of a visual pigment. The most prevalent one is called Dobson, which is light sensitive and the Dobson molecule change your shape when light hits it, that makes ions move and that creates a neural signal. The other part of an eye physically in higher animals anyways, is an optical system which lets images be focused by a surface to the eye and by a lens to adjust that focus in to make the image sharp upon the retina. But as I've said, retina is brain. It has several layers of cells which actually think we think in our eye before images ever get up to our brain.
Michael Marmor: [00:06:38] We don't send a photograph up to the brain. We don't have enough cells in the retina to do that. Images get processed. They get processed to simplify, decode them. So we can use less cellular energy. When we sell things up to the brain, we we look at edges and contrast and are very sensitive to lights and darks. And color is then added on as a sort of a secondary sensation that that that higher mammals really only the only the humans in the great apes have full color sensitivity. Your dog and your cat. Colorblind. Red. Green. Colorblind. And so we send a coded image up to the brain, which then receives it first in the primary visual cortex in the back of the brain, and then that information gets sent out to multiple centers in the brain, which eventually interpret faces and print and all the things that make make our visual world possible. The eye is the starting point, and the retina is where it all, all begins. And that's the common element in all animals that have vision. When I talk about art, I'm talking about to teach you about how the eye begins the process of seeing. And the way that we see contrast and color within the eye before it ever gets to the brain. Really provides the power of the eye and the constraints upon what we can see in the world.
Tyler Johnson: [00:08:03] That was beautiful. That was just perfect.
Henry Bair: [00:08:07] So thank you, Dr. Romer, for for that for that amazing description. You just alluded to art, which we know is a very, very big part of who you are and your interest in your work. Before we get to that, I just want to go back a little bit to your mention of one of the things that you love about ophthalmology is that you are able to engage in research, but at the same time engage in surgical work and have these longitudinal patient relationships. I'd like to touch on on some of those points for our listeners, especially for those who may not be ophthalmologists, which I would assume are most of them. Can you tell us in broad terms what your research has focused on and some of its clinical implications?
Michael Marmor: [00:08:58] Sure in this to now lead us to several points that you've alluded to. My research was basic neurophysiology. I studied the retinal cells and a layer of cells called the pigment epithelium right behind the retina, which is critical to retinal function because it supports the retina controls. Ionic movement proteins to the retina. Looked at the electrical signals that came out of these cells and how they work and how they support the retina and how we can use them clinically. You know, we can record electrical signals from the eye, from the retinal cells just by putting a fine wire on the surface of the eye. And this is done clinically with a test called the electro retina gram. It's not hard to do. We do it for diagnostic purposes to learn about diseases that affect the retina. And so I was studying all these processes, working with working with animals and trying to understand really the basic mechanisms of some aspects of the retina. It's a part of a broad sense I have, and this was always a dominating part of my teaching and understanding of ophthalmology is that you can't be a good doctor in any field if you don't understand how the diseases work and how the tissues work that make the diseases. Otherwise all you're doing is following numbers or following a cookbook and you're not really treating people and you don't have the ability to judge when something is going right or going wrong, or when this may be a new rare disease.
Michael Marmor: [00:10:30] You really have to understand physiologically pathophysiological what is going on. And so that always drove my teaching and my understanding. Now, what I did with ophthalmology, however, is is is more complicated. And I'm not your typical ophthalmologist. I loved surgery was one of the reasons I went into it. And every ophthalmologist learns to do cataract surgery very, very well. And I did for about 20, 25 years. But my interest, of course, academically is in the retina. And I gravitated to a small part of medical retinal disease which deals with hereditary conditions mostly that affect the specific function of those photoreceptors and inner retinal cells that I was studying. These diseases mostly are untreatable and just beginning now to be treatable with gene therapy that's coming in but doesn't get quite work. Ironically, after about 25 years in the field, I, I gave up cataract surgery because I wasn't doing very much of it and worked with these diseases trying to help my patients understand what was going on, why what they could hope for, what was realistic. The irony was that I chose ophthalmology because I didn't want to do psychiatry, and I ended up practicing a lot of psychiatry with my patients.
Henry Bair: [00:11:53] I think that's a that's a really, really fascinating point. You know, you talk about how a lot of the the diseases that you were counseling patients on didn't really have curative interventions or even interventions to slow their progression in some cases. Can you tell us more about what those patient interactions were like in those cases? What do you do for patients? How do you comfort them?
Michael Marmor: [00:12:18] Well, you comfort them with understanding. People can deal with disease as doctors can deal with disease if they understand it. If they don't and somebody just says, Oh, you have retinitis pigmentosa, you'll be blind in ten years. They go home and cry. But if you tell them, look, let me tell you something about this disease, how it changes, what you can understand, what you can follow on the web now that less people go away feeling that they are somewhat empowered to deal with it. Ophthalmology does have a little bit of a problem that. Many ophthalmologists really want to do surgery, as most surgeons do, and don't spend a lot of time with their patients and don't take the time to help patients really understand what they're doing and why and what choices they have. And I think there's no field of field of medicine, no matter how technical that doesn't gain from from developing a rapport with your patients and taking the time to understand people. People often say, well, what are the things you ask with a patient comes in into your office and many doctors start asking about symptoms and does it hurt here and does it do that? That's not the right question. The question is to ask the patient, Why are you here? What can I do for you? And then if you don't get an answer that helps you diagnose, then you can ask, ask things more specific. But you'd be surprised how many patients come in to see the doctor for something other than what you think they do. And sometimes other than you can do much about. But at least then you know what it is and you can help them.
Tyler Johnson: [00:13:59] So, you know, sight maybe most of all the senses, with the possible exception of hearing. But I would say sight even more than that is the one that is so fundamental to the way that we process the world, that most of us, myself included, aren't even aware. It's a thing, right? Because it's not it's like the fish, right? The proverbial fish trying to understand the wetness of water. It just is right that that which within which we are enveloped is the visual world. And so I guess that's just to say that I would be interested though I imagine this is a hard topic in some ways to hear you talk about what is it like for people, particularly people with chronic progressive diseases, to slowly lose their vision over time as the doctor who's taking care of them, seeing that experience and sensing it a little bit vicariously, what is that like for them?
Michael Marmor: [00:14:57] This is a topic that is complex. We have to be careful. People who are who are deaf live in a very functional world and find other senses to satisfy their needs and to understand what's going on. And we shouldn't be Disparaging sight is important to all of us. And people that are losing sight have to learn to cope with it, but they cope with it by taking on these other alternative means of hearing and touch and finding other ways of knowing, knowing what's going on. They lose a lot that they can't get back. You know, the great composers like Beethoven and Smetana did many of their best works, compose their best works when they were totally deaf, essentially. Why? Because there's a surrogate for music you can write down on a score with something. Sounds like there's no surrogate for vision. There's no way to describe words or to something that you could read or tell someone about exactly what a painting or even a scene out in the out of the garden looks like. So yes, there is definite loss and the best you can do is help people to grow with it and learn from it, to figure out how they're going to get around it and how they're going to cope with the things they they need to do, whether they're by themselves or whether they have family or support team. But it's not something that I can easily answer. I deal with science. I'm not a, not a psychiatrist. I'm not a physical therapist. I'm not a philosopher.
Tyler Johnson: [00:16:33] Fair enough. Well, I think you have a little bit of a philosopher, but.
Henry Bair: [00:16:39] Well, I mean, yes, You are not the psychiatrist and you're not the philosopher, but when you're with a patient sitting in an exam room with them and they bring these concerns up with you, they're worried. They're scared. What are some things you say to them? And how do you teach residents and medical students and others in their medical training on counseling patients in these circumstances?
Michael Marmor: [00:17:04] Badly, because we don't have the opportunity and because the kind of stuff that I did, I used to say, Well, what's your specialty? I practice acutely remunerative disease. Because the diseases that I dealt with took a lot of time, a lot of talking to no surgery and didn't earn any money. So it's hard to get residents or even fellows in Retina to spend any time with me when they did. Great. We walk around together. We walk in and see patients together. I'd ask them to start talking to the patient and see see how it goes and learn and watch. Watch some of the things that I say. And what you're trying to do is do as I say, help people understand to to lessen the evil. They're not going to be blind overnight. The diseases that I dealt with took years to gradually affect vision. And now there's more and more hope that you're going to be able to resolve some of those problems. And you try to help people to understand the time frame, to understand that there's always hope, hope for something. If it's not vision, it's going to be other senses. There's hope for things that you can do. And I think if you can instill both understanding and hope, you're doing what you can and you're doing what a lot of doctors don't.
Henry Bair: [00:18:23] Dr. Marmor, I want to change the course of our discussion and explore your engagement with the fine arts. Just from the way you've worked it into our conversation so far. Your passion for the arts, whether it's musical arts, literary arts or visual arts, is quite apparent. And this passion is, of course, attested by your writings and the classes you teach on vision and visual art here at Stanford. If you walk into the main hospital or the eye clinic, you'll quickly notice the abundance of artwork hanging on the walls, many of which you donated. If you roam around the art museum on the Stanford campus, you'll come across an entire exhibit bearing the name of your foundation. I'd like to explore your lifelong love for the visual arts. What first got you interested in them and what was your journey in art collecting?
Michael Marmor: [00:19:15] It's sort of a long story again, because I've been around for a while. I grew up with art in the house. My parents were art collectors, mostly of pop art in Los Angeles in the sixties and seventies, and so there was always art on the wall. I never gave it much thought. It was just there. It was a part of my life and a part of our house. I did not train in art. I don't have a degree in art or take it in college, but I always liked art. And we went to museums and I became exposed gradually to more and more. I played the clarinet and played played classical chamber music all my life. So music was a part of my life. Of course, read books and had a good liberal education and all that sort of stuff. So so I was broadly informed and art is a part of that. As I got into the field of ophthalmology and was learning about vision, my field was the retina. But the outcome of that, of course, is vision. Art. Visual art, anyways is a field that involves seeing and in knowing what you're seeing and artists doing what they can with the vision that they have and helping us, or sometimes trying to guide us to see art in certain ways. And I began to think about how could my knowledge enhance art? And along with a colleague who's a coauthor on my books, we began to give lectures at the American Academy of Ophthalmology about artists who had had eye disease and how it affected their work and just how the how the mechanisms of vision about how you process light and dark and color and shadows and perspective.
Michael Marmor: [00:20:51] For quite a number of decades, I taught an undergraduate course here at Stanford, not in my job description just because it's fun. Undergraduates are wide eyed and bushy tailed and not as bored and busy as the ophthalmology residents. Or residents in other fields too. So it was fun to teach them about art. Most of the undergrads didn't didn't have much exposure to great art. But it's a part of a larger sense that you touched on Henry Which is that. All of culture, art and music, great literature, the history of the world and of our field of ophthalmology. These are all components of culture and of the humanities, which are not a part of medical education per se. They. Medical education increasingly is technical or biochemical. There are facts to learn, too many facts to learn. Many of the facts that you learn in medical school are of any use at all. But some obscure professor who has sway in the medical school says, You've got to spend an hour on my liver enzyme. And so you learn all about it. And even though you'll never use it.
Tyler Johnson: [00:22:04] You're not supposed to let that secret out to the medical students on the podcast. They're not supposed to find that out until they graduate.
Michael Marmor: [00:22:09] Yeah. Yeah. Well, when I was a medical student at the Stanford of the East. Harvard. I saw, I don't know, half a dozen cases of cases of alveolar proton gnosis in the children's hospital, but never saw a case of measles. But the point that I'm getting at is that is that being well rooted, being aware of the world, being aware of the cultures, that different people come from, being aware of the beauty and the relief from from tension that you can get from looking at a painting or listening to music or reading a good story. These make you. Better, better people and better doctors, better able to discuss field of medicine, to act as ambassadors for medicine. We lose out if all we're training our technicians in the field of medicine. And it's hard to to get the humanities into medical school. I've been struggling here at Stanford and at Harvard to get the medical schools to add some humanities. Obviously, they're not going to take one third of their teaching time and teach about French literature. That's counterproductive. You're in medical school. But to just keep keep in touch with humanities, it's hard to do. All the deans think this is very important, and they'll tell you so, but they won't do a damn thing in terms of the curriculum. So these are ongoing struggles, but it's a it's a strong belief in mind that the best doctors in terms of their patients and in terms of the reputation that they have in our field and the way they serve as ambassadors in the literature and on television are smart, well rounded cultural people.
Tyler Johnson: [00:23:52] So I'm going to guess that I speak for both Henry and I. So Henry and I are a little bit unusual, although many of the guests on this program are similar. But in that he was a medieval studies major and I was an American studies major. And I know to the point that you were just making about medical education being arguably overly technocratic. I know that when I went from doing all of this sort of deep reading and synthesis and argument and counterargument and tons of writing and all that kind of stuff to medical school, which was just memorized, memorized, memorized, memorized, memorized, memorized, memorized. I felt like a guy who had gone from being a really balanced, well sculpted bodybuilder to a person who had a bicep that was like, you know, two feet around but no muscles anywhere else in his body. So that's all to say that I think we're Henry and I are totally with you in. And part of the purpose of the podcast arguably is in trying to round out the sort of broader concept of medical education. But I would like you to dive a little bit more deeply into, which is to say, we totally agree with your point, but can you speak as someone who's been a patron of the arts and very involved in the arts, what is it that you think a study of the arts brings to the study of medicine that can't be gotten in any other way?
Michael Marmor: [00:25:12] It brings quite a number of things. It brings insight into how we see and to how we think. What does it mean to say something is good or bad or pretty or not pretty? And that comes into how you practice. Is this disease important? Does it affect people? How do people think about it? It's fun. It's relaxing. It gives you a break from other ways of thinking about things. And that's that's very vital, too, If you spend all your time in technocracy, so to speak, thinking only about building up that biceps of your brain, you lose sight of the fact that there are other things to do and you can get bored. You can get overly stressed. The arts do an awful lot. They make you in touch with other people and other ideas. And that's vital. And that's vital in science too. If you spend all your time thinking, I've got the cure for cancer and never stop to look what other people are doing or what other type of cancers are out there or what we're learning about it. You're not going to be a good scientist. It takes a breath of awareness to stay involved with everything, to stay happy, to do all sorts of things. But frankly, just just being able to look aside now and again from that textbook and sit back and listen for 15 minutes to Mozart or to Bullock. Is good. It's therapeutic. It's a part of life and it makes you a better person.
Tyler Johnson: [00:26:43] That really resonates with me on at least two levels. The first one is that I absolutely agree with you that I think the focus, especially of early medical education, is incredibly imbalanced. I don't I imagine that it's that way for complicated historical reasons, which, as you mentioned, once it's established in the bureaucracy, it's very difficult to change something like that. I think it really is unfortunate because I think it impoverishes our medical education and I think it sort of slants people toward a very narrow way of thinking about what medicine is and what it means, which then biases the way that we practice as doctors further down the road. And but then I also think, you know, there's one of the main purposes for this podcast is to try to battle the epidemic of physician burnout. And I agree with you that I think there's a there's an almost spiritual element to this, which, you know, these are my words, not yours, but building on what you said. If medical education becomes overly technocratic, it can come to seem like the body is nothing more than a really, really, really complicated machine that needs a really, really, really skilled technician to fix it. This is nothing against machinists or technicians or anything else, but it's just to say that that's not all. Medicine is right. We cannot be boiled down just to neuroanatomy and cellular physiology. There is this other element to being human that art captures that a biology textbook just doesn't. And I think you're right that that exposure to art helps to integrate those things together.
Michael Marmor: [00:28:25] That's very true. I think that's why or should be why people go into the field of medicine. The money isn't what it used to be. So why do you do it? Because it's fun to work with people. It's fun to know the science, but also to deal with people. And if you don't take pleasure in that or get some reward from that, probably medicine is not the greatest field for you because you will burn out. We burn out sadly nowadays, in part because of the constraints of how our field works, where you have to see so many patients and so much time and all that sort of garbage, which is sad because it is taking the time and finding your own niche to to serve the medical community that you work with that is so vital. And most people going into medicine are broadly educated. And then under the pressures of medical school, they start to lose contact with it. And the same thing happens even in medical school, going on into the specialties. Students occasionally ask me, Well, gee, I'm in college and a student being a doctor, what do you think I should do? You think I should take advanced chemistry or physiology course? And I say, Hell no.
Michael Marmor: [00:29:31] Take art. Take French history. Take archeology. Because you'll never have a chance to do it again. They're going to teach you more in the first two months of medical school than you'll ever learn in your college course. Anyways. Think of this as an opportunity. And the same when you're a medical student thinking of ophthalmology or neurosurgery or oncology. Don't take an elective in ophthalmology or neurosurgery or oncology, because again, two months into your residency, you're doing more than than you'll ever learn. Take a chance. Learn something else. Take endocrinology, take psychiatry, Take something that will enlarge your sense of the patient and of medicine as a whole. Then we obviously, we all do have to specialize. At some point, we have to learn a certain amount of facts, but try to put them in perspective. We learn too many facts. When I trained, which was a long time ago, the antibiotic was penicillin. That was it. And we got along.
Tyler Johnson: [00:30:36] Yeah. You know, it's funny because as you talk, I'm reminded that I feel most doctors do a pretty good job at being good at the thing that they're supposed to be good at. Right. But every once in a while, you meet one of those doctors, whatever their subspecialty is, who somehow seems to have integrated the whole thing. Right? The cardiologist who still has an in-depth appreciation of renal physiology and still knows all of the bones from orthopedics and still knows better than I do. The way that light hitting the cells in the back of the retina transfers an image to the brain, Right? There are rare doctors who know that. And then above even those are the even rarer doctors who have a holistic understanding of human physiology, that their subspecialty is placed in the context of that. And then on top of that, have a holistic understanding of humans as humans, right? And see people as people in addition to understanding all of the complicated functioning of what's going on inside of them. And I think that's a you know, in some ways, obviously, there's just too much known about all of the subspecialties at this point for anybody to know anything close to all about any of it, let alone all about all of it. But still, that idea of a holistic doctor who really understands both human physiology as part of a functioning whole and then humans as functioning wholes is certainly something aspirational, if nothing else.
Michael Marmor: [00:32:02] That's absolutely true. And in vital, as much as most of our technical fields realistically are are narrow and deal with the particular subspecialty we do deal with. Not all of it, because diseases of the eye aren't limited to the eye. They involve the body. They involve endocrinology. They involve inflammation. Oncology deals with with tumors. But why does the tumor grow in some people and not in others, and have a bigger effect on some people than others? Everything is involved in you find more and more if you start thinking about it, or at least being open minded to it, that the subspecialty issues that you're dealing with have contacts elsewhere. And if you don't keep that in mind, you lose the chance sometimes to find a new disease or a relationship or a side effect. That's actually vital. So it is important we want to be generalists in in medicine and then the business of culture is just going one step further back, too. We also want to be generalists in the world at large.
Henry Bair: [00:33:06] So we've been talking a lot about the importance of a holistic approach to patient care and to medical education. And earlier in this conversation, you discussed your concerns about the hyper specialization of medical training and the outsized emphasis on technical knowledge and mastery. So in your ideal world, how would we introduce medical, humanities and art appreciation into medical curricula?
Michael Marmor: [00:33:42] That gets complicated because one has to deal with the realities, of course, of learning the facts and of the amount of time that's available. Time is not an issue because, as I was pointing out, a certain amount of medical school are obscure data that get introduced into the curriculum, and if the deans wanted to pair them out, they could. It's a matter of priorities. What do you want to spend your time with? I think there are two aspects. One is just exposure, just being continually aware of the humanities that are out there partly to to have relief from stress, but partly just to be aware of what's going on. So having an environment where there's art, music and history going on around you and to be able to take part in it when you want to or to the extent that you want to, is vital. We have some advantages here at Stanford. For example, we're on a great university campus with music and culture and art and theater and political science lectures and all sorts of things going on. Not that many medical students get out of the out of the hospital to deal with them, but they're there. And there's a certain sense of a world outside of medicine. I would personally be delighted if a part of medical school every year ongoing. There was one sort of informal seminar that the student could choose to take some course in the humanities, whether it's great literature or music or art or drama or something without without a lot of stress, not too many hours, not not worry about a grade, but just to keep a hand in the humanities, going along with the with the intense study that you're doing.
Michael Marmor: [00:35:25] But, the fact of the matter is that if something like that is not required, it doesn't get done. And this is where the deans could come in, but don't come in. Would that be valuable? I don't know. It's something that's sort of in my mind that maybe it maybe it would if it were not too much, if it were a couple of hours a month to sit down in a seminar with somebody from a different field and talk about things other than medicine and stay informed and stay aware, I think these are helpful things to do. Obviously to have opportunities to exercise whatever cultural interests people have. And we have some of that here at Stanford in a program of medical arts and bioethics that gives students a chance actually to have their concentration in fields other than than basic science or traditional medicine. But not many students do it. So my ideal world would be to have a certain amount of required involvement, not so much that it's a burden upon the study you have to do, but just enough to kind of keep you aware and involved and interested.
Henry Bair: [00:36:33] Yeah, to your point, as a medical student at Stanford, I was one of the few who did use that curricular flexibility to take classes on bioethics, medical humanities and courses on arts and literature. There were a small group of classmates who would take these classes with me, but we were all already interested in the fine arts in the first place. So the key question really is how would we engage students who aren't already interested in the arts? And of course, the catch with requiring the arts is that you risk alienating those who don't already have a predilection for it. But I think your idea makes sense. We would require it, but with a light touch, the emphasis wouldn't be so much on learning anything in particular, but rather on self enrichment and enjoyment.
Tyler Johnson: [00:37:22] Well, it is a little bit of a funny discussion, right? Because while on the one hand, it's true that truly requiring something rigorous. Right. If everybody had to take some sort of seminar where they had to write a a paper at the end or something, that would probably not engender a lot of happy feelings, but like but who really just absolutely loves getting up in the morning to memorize all the complexity of the brachial plexus. And nobody says, well, they don't really like it, so we're not going to have the memorize the brachial plexus anymore. Right. You just even though I haven't used anything to do with the brachial plexus in any meaningful way in my entire career, but I still had to learn it, right. Which is just to say that I. It's just a sort of a funny. Commentary on the fact that I think even the three of us who are so partial to the medical humanities, even we have been stewed in the juices of technocracy to the point that we want to say, Well, yeah, it's really important, but we shouldn't. We have to be really careful because we don't want to engender bad feelings by actually making people do it well. I mean, I'm just I'm not even making a proposal so much as I'm just making a commentary on the fact that it's still a little bit funny that, like even those of us who want to fight the technocracy can't totally fight the technocracy. It just gets baked into you as if learning the intricacies of the brachial plexus is more important than understanding people as people and the stuff that the medical humanities can teach you.
Michael Marmor: [00:38:40] Yeah. Yeah. These are. These are tough issues. I can still rattle off the bones in the hand. Not that they do me a lot of good these days. The problem is exactly as you say, that you can't beat people over the head. You can't force them take things that they really don't want. The trick there, I think, is having enough choice and enough opportunity. For example, if you're going to have a low stress and I have to stress the low in that a low stress humanities involvement that's sort of ongoing through through medical school, then you have to give give students a fair amount of choice as to what their topic will be and who they might have the discussions with. And you need to try to gather, which I think in most school environments is not hard people outside of medicine to help guide these exercises because doctors who are who say they're interested in art or music myself are not necessarily the best people to teach about art or music except in a medical context. I'm not I'm not an art historian. I play the clarinet, but I can't. But I can't teach you much about music. So you need contact with people outside of medicine also who have the viewpoint and the vantage point that's outside the technocracy in which we were all raised.
Michael Marmor: [00:39:53] But it is hard and the pressures of learning the facts that everyone feels we have to learn is intense. Interestingly, the modern world should make some of this easier, although it hasn't yet, because medical students don't need and probably shouldn't learn as much of the facts as they used to. Because now with the web, you look things up, the residents come around as they leave. Gee, that's interesting. What was that syndrome? They punch in there on their iPhone for 2 seconds and they come up with the answers and they learn about a whole lot of antibiotics. But next year, when half of them have been tossed out, they're having to learn about new ones. So it's a changing target now and non medicine. We need to be learning more how to use the information tools that we have available. Again, keeping things in perspective, but we really shouldn't have to spend in a sense, as much time memorizing hard facts because other than perhaps the bones in the hand, most other things are going to change.
Tyler Johnson: [00:41:04] Yeah, it really is funny because I. I'm less experienced than you are, Mike, but I even for me, when I was in medical school, there was still this quaint idea that you had to have the facts at your fingertips because that might save someone's life, right? The fact that you knew some obscure facts, some obscure diagnosis, that you had read something in a textbook once and could remember it, I mean, you could look things this this was in like the the late aughts, so you could look things up, but it was still kind of clunky, look things up on the web and whatever. So there was still this idea that you really had to know things. But now with smartphones, as you say, it seems almost entirely superfluous because we are all functionally cyborgs, right? I mean, our our cell phones are so tightly integrated into the way that our brains work that IT stuff stored on the web may as well be stored in our brains as long as you know how to find it.
Michael Marmor: [00:41:55] It's a compromise, because obviously there are things when you're facing a patient or facing a crisis or facing an emergency, that where your knowledge comes in, where you don't have time, even for the for the smartphone or where you have to make a judgment about what to do or a patient asks you a question and when when you're going on rounds with your group, you can take time to look up on an iPhone. But when a patient asks you a question, it's very bad karma to take out your iPhone and say, Hey, well, let me look that up. That doesn't that doesn't look good and it doesn't give confidence. So there is a core of knowledge that that, yes, you do have to have and should have. Everything is a balance between all of these things.
Tyler Johnson: [00:42:39] Your point is well taken that of course, doctors have to know things. But I'm just saying, let's put it this way. If you think back, this is no longer thankfully true. But until just a couple of years ago, one of the major almost universally recognized selection criteria for any residency was your score on step one. And step one is nothing but forced regurgitation of medical arcana that is almost entirely useless, especially in the era of smartphones and Google. I mean, it is just it is almost truly a pointless exam. And so and yet that was one of the main siphoning criteria for residency programs. Right. Which is just to say that if you're I mean, in medical education, the way that you really prove what the coin of the realm is, is by what you use to choose who gets to be in the most selective next step of the training process. Right. And so anyway, all of that is just to say that while of course it's true that doctors need to know things, I'm I am hopeful that the fact that step one is now pass fail is indicative of sort of a shift away from the emphasis on memorizing medical arcana and towards a more holistic understanding of people and pathophysiology and all the rest.
Michael Marmor: [00:43:53] Well, this is interesting and again, a complex issue far outside of our our sphere of knowledge, frankly, to deal with or perhaps social competence to deal with what makes a good doctor. What should you choose to be a doctor in in medical school? I'm still old fashioned enough to say the doctor should be smart. There's a lot to learn about the body, to know about the body, and to intuitive about the body that it takes a good mind to deal with it. But then how do you tell when you're choosing people for medical school? Now everything is pass fail. The colleges are pass fail. I didn't realize that the boards were pass fail, but I'm not surprised as so the students come in and they send in their applications and they say, How do you tell? Everybody's got the same good record for medical school? Everybody sends in good letters, nobody's going to send a bad letter. How do you tell you sit down and talk to somebody for a few minutes and some are more articulate than others. All right. That's perhaps an index, some are psychopathic and they make the best interviews, but they're not really going to be the best doctors. It's very tricky. For a while, UCSF in San Francisco wouldn't consider Stanford medical students because they didn't get grades and they couldn't. They said we couldn't judge that. We couldn't tell who is any good. But I think they've changed now because I don't think they give grades either.
Michael Marmor: [00:45:10] It's a real problem. How do you tell by how people are articulate, by how they can solve questions, by what they know? I think there is a balance somewhere of not tossing out all of the knowledge that people do need to acquire, finding some way of judging or evaluating how people can solve problems or deal with information or integrate information. These are all skills that are going to make you a better doctor. But we're floundering to find ways of ways of determining it. And we end up now medical schools. Look at, well, who got a prize for ballet or won the race or happened to publish something or worked in politics or work for some volunteer organization. And so the poor student is trying to get into medical school or trying to build their CV full of all this crap that they're not really. Are interested in. But feel. Feel. Well, if I don't show that I can do all these things and get some prizes, I'm not going to get into medical school. That's not that's not very productive either. But I don't know the answer. I think it's a hard thing to do. You know, when you talk to somebody long enough, you have a pretty good idea what kind of activity and breadth and smarts they have. But. But not a ten minute interview.
Henry Bair: [00:46:29] Well, Dr. Marmor, you have been so generous with your time. Typically, we end our episodes with asking for any advice you would have for our listeners. But in this case, I think you've already given us so much to think about. So instead, I'm going to end by asking you what are some of the most impactful works of art you have encountered and why?
Michael Marmor: [00:46:52] I will answer that by saying I can't. Because. People ask me, What's my favorite painter? What's my favorite work of art? And there isn't one. How do you compare a Picasso with a cave painting with a Navajo pot, with a abstract work? They all bring different things to the table and different kinds of joy and understanding and complexity. So my greatest advice about art is don't get hung up about one type, but look to see it all and to enjoy it all. And the same thing goes about music. Sometimes it's a struggle. I was raised in classical music and I love it, but I try to listen to modern music and to some of the newer music that's coming along and some of the newer art that's coming along. Because I think if you don't continue to broaden your horizons as to what people are doing and thinking, then you lose contact. I will say that if you want to learn something about. The eye and vision and art that my new book, The The Artistic Eye, will be out at the end of 2022. And I think many people interested in medicine, in the arts will hopefully find that interesting to.
Henry Bair: [00:48:05] Great. I'll look forward to reading that book. So again, thank you very much for your time, Dr. Marmor. And this was wonderful. So thank you for the conversation.
Michael Marmor: [00:48:14] It was good. It was fun to do. And I hope. Hope you have enough things to work with. Probably too much.
Henry Bair: [00:48:22] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:48:40] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:48:54] I'm Henry Bair.
Tyler Johnson: [00:48:55] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.