‘The Rhetoric of Medicine: Lessons on Professionalism from Ancient Greece’: Book Review

Adam Hayden reviews Nigel Nicholson and Nathan Selden’s The Rhetoric of Medicine: Lessons on Professionalism from Ancient Greece (Oxford University Press, 2019).

Co-authors Nigel Nicholson and Nathan Selden might strike you as an odd couple. Nicholson is a classics professor, a dean of faculty, and an expert in ancient Greece. Selden is a neurosurgeon, department chair, and past-president of the Congress of Neurological Surgeons. Just as curious as their writing partnership is their subject: an analysis of physicians working in late-archaic and early-classical Greek periods [550 to 400 BCE] and those physicians’ place in society. Nicholson and Selden’s thesis is that a study of these ancient healthcare practitioners holds lessons for contemporary American medicine. Those lessons do not concern historical procedures or evolving techniques, but professionalism, namely, medicine as a profession, its societies, structures, and cultural characterization. They do this through a study of rhetoric rather than, say, ethics or literature.

The Reviewer at Work

At first glance, little about this project made much sense to me: How do a classicist and a neurosurgeon become writing partners? Why rhetoric? What is instructive to the modern healthcare professional from a study of early-classical Greece? I thought a classicist and a surgeon would not find much to talk about at a cocktail party, let alone collaborate on a book! Yet it is just this esoteric selection of topic, mix of styles, disciplines, subject matter, and expertise that makes The Rhetoric of Medicine such a fascinating and fun read, relevant for Medical Humanities students and educators, clinicians, medical historians, medical ethicists, and curious general readers alike. I hope you’ll consider placing on your bookshelf or your syllabus. Let’s dig in.

“Medicine and scientific developments,” Nicholson and Selden begin, “do not stand outside of culture but participate in and are shaped by their larger societal context” (14). The collision of science, medicine, and culture lead Nicholson and Selden to adopt rhetoric to advance their analysis, but this is far from the lay definition of rhetoric as political double-talk and straw argument intuition-pumping. Nicholson and Selden’s method is sound and rational. They are not interested in hot-button issues and heated debates; rather, “the mundane, everyday practices of medicine” (7); “questions of the conceptualization and representations of physicians and medicine itself” (8); in short, “how the stories ancient Greek and modern American physicians tell about themselves can affect behavior, and thus patient outcomes, positively or negatively” (ibid.). Taking this tack shifts the impetus away from whether stories are true or false, to discover the meaning they offered the culture. Framed in this way, Nicholson and Selden explore several issues relevant to medical professionalism today.

Nicholson and Selden selected the ancient Greek period as a flashpoint for poignant and topical comparisons with contemporary American medicine for a number of reasons (14-15): this period saw the distribution of the Hippocratic corpus, the first medical documents written for circulation, representing an advance in medical knowledge; the period reported the first public criticism of a physician doing something immoral for money; and the period included economic upheaval and the advent of coinage and commodity exchange, posing contentious questions about fee exchange for medical care. Moreover, given the Greek fascination with athletics, the ancient Greek period flourished with knowledge of diet, exercise regimens, and the treatment of athletic injuries, introducing competition between physicians and athletic trainers. The physicians of late-archaic and early-classical Greece were also the first to commemorate and memorialize themselves, “precisely for their work as physicians” (15).

These public displays were significant because physicians were viewed negatively by the Aristocratic guard that Nicholson and Selden detail in their many analyses of odes and histories told about physicians at that time. Ancient Greek historian Herodutus tells of the itinerant physician, Democedes, who is charged with sparking a war with neighboring Persia, risking Greek democratic freedom (15; 147ff.)—a story almost certainly fabricated. Nicholson and Selden explain, consistent with their historiographical and rhetorical lenses, that stories like these reveal the social and symbolic roles fulfilled by physicians (161). Democedes, likely a real physician, served a role in Greek literature as receptacle for Aristocratic fears, including physician fee-taking (76), portable wealth (62), access to female patients that physicians may take advantage of sexually (64), and lack of adherence to social norms (ibid.) Interestingly, as Nicholson and Selden point out, the fear that a physician may take sexual advantage of patients is reflected in the Hippocratic Oath’s commitment not to do so (64n28).

Democedes traveled to the Persian court and successfully treated the Persian King Darius. Rather than emphasize the healing act, Herodutus’s telling of this story sees Democedes as contractor, bound to the marketplace, rather than healer. Nicholson and Selden compare this story with similarly themed stories featuring in Hebrew scriptures: Joseph and Daniel (159), but whereas these Biblical figures earned respect in foreign King’s courts, Democedes is portrayed as a servant or slave: “Making money in the way he has made money is seen as being incompatible with being free” (160).

Nicholson’s and Selden’s historiographical interpretation of these stories, writing, “[w]e are concerned less with whether a story is false than whether it is unhelpful” (8), and their explicit connection to similar Biblical narratives, reminds me of a favorite theologian, the late Marcus Borg (2001), whose guiding commitment was to take the bible seriously, not literally, quipping, “[n]ow I don’t know if it happened this way or not, but I know this story is true” (50).

Nicholson’s and Selden’s book is so compelling for just these sorts of reasons: exploring the social and symbolic narratives that turn a mirror to society and reveal transcendent truths about our conception of ourselves and its bearing on behavior.

I loved Nicholson and Selden’s foray into the stories told about and by ancient practitioners, in the words of Greek poets like Pindar, the Greek historian Herodotus, and the philosopher Empedocles. The criticism of Democedes as prizing fee taking in exchange for freedom led the Greek public to view the physician cynically and uninterested in freedom and autonomy. The modern analogue is the concern that healthcare is a commodity rather than a gift (167), and in the modern consolidation of the healthcare market to undersell competitors and drive them out of business: “[D]octors become captives of their work… focusing increasingly on services that garner more income” (170). In both the ancient Greece and modern American healthcare models we see commodification as a risk to autonomy.

I see these connections in the contemporary era of entertainment streaming platforms and serial medical dramas. Modern medical stories reveal and draw social criticism akin to that Nicholson and Selden uncover from ancient Greece. The medical television series New Amsterdam is the target of a scathing critique published in The Atlantic, complaining, “[b]ut while accuracy has never been a requisite of prime-time programming, skewed medical dramas such as New Amsterdam can have a more insidious effect, poisoning how the public views the health-care system and physicians” (Trogen 2018).

Nicholson and Selden conclude their book with an important discussion of the physician’s relation to their own body (chapter 7). Addressing this topic is especially timely as depression and burnout rates rise for both practicing clinicians and medical students (221). Nicholson and Selden present a case study from ancient Greece, involving what today we call the ‘clinical note’. The physician recording this encounter with a seriously ill patient writes in the third person (210). Patient vital markers and medical interventions are recorded as having happened, without the physician writing in an active tone to capture their role in administering treatments.

This subject-free, third personal view is common in the Hippocratic corpus. Nicholson and Selden use the language of the Princeton University classics professor, Brooke Holmes, who refers to this detached method in the Hippocratic texts as the disembodied physician (214). Nicholson and Selden follow Holmes in assessing that this rhetorical device of disembodiment is foundational in the construction of authority in Western medicine (221). The rhetoric of disembodiment drives a wedge between the physician and their body, in effect, undermining a physician’s identification with their own physical states. Alienated from their own bodies, physicians view illness as a personal failure (223), leading to depression and burnout (ibid.) Disembodiment, Nicholson and Selden explain, “impedes a genuine empathy with the pain, sorrow, and fear associated with serious illness” (225).

Through understanding these stories physicians tell about themselves we may understand how best to combat burnout, depression, and other maladies that plague contemporary American healthcare, by “creating environments and expectations that realistically reflect the limitations imposed by the human physicality of physicians themselves” (231).

Nicholson and Selden admit that their call to reconceptualize medicine by studying its Greek origins through a rhetorical lens is no easy feat, “we need to be realistic about how difficult such work is” (235), yet I found a promising pathway forward by returning to this early-classical period. As Nicholson and Selden say, “[t]he gains to be realized by both physicians and the public…are tangible” (236). My review is inadequate to address the rich content of the book, but at minimum, I hope you’ve considered adding The Rhetoric of Medicine to your wish list.

References:

Borg, M (2001) Reading the Bible Again for the First Time: Taking the Bible Seriously, But Not Literally, New York: Harper Collins Publishers, Inc.

Trogen, B (2018) “New Amsterdam Is a Medical Drama That Fails Doctors—And Viewers”, The Atlantic November 28, 2018, accessed at https://www.theatlantic.com/entertainment/archive/2018/11/new-amsterdam-nbc-show-physician-distrust-bellevue/576712/.

Adam Hayden, MA, is an independent scholar and research assistant affiliated with Indiana University-Purdue University, Indianapolis. Adam’s own graduate study was abbreviated by his diagnosis with the aggressive brain cancer, glioblastoma, but he continues to apply his training in medical humanities and philosophy toward writing and speaking. Read more about Adam on his personal blog, Glioblastology, and follow him on Twitter: @adamhayden

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