welcome my name is Jeff Resnick I'm chief of the history of medicine division here at the National Library of Medicine uh thank you for joining us today those of you here in the Lister Hill Auditorium and those of you watching remotely uh today we're going to be hearing the 10th Annual James H Cassidy Memorial lecture in the history of medicine which is part of the nlm's 2018 history of medicine lecture series now for the past decade the nlm history medicine division has hosted this special lect
ure in memory of our late colleague Dr James H Cassidy renowned historian of medicine 50-year employee of nlm editor of the printed bibliography of the history of medicine and a bibliographer for the histline database and these are all have been essential tools valued by countless Scholars over many decades during the course of his distinguished scholarly career Dr Cassidy received every major honor that the national professional Society in his field could bestow that is of course the American A
ssociation for the history of medicine in addition to the Welch medal which you received for his books American medicine and statistical thinking 1800 to 1860 which was published in 1984 and his book medicine and American growth from 1800 to 1860 published in 86. Dr Cassidy was awarded the association's Lifetime Achievement Award and delivered its honorary Garrison lecture as well he also served as president of the association from 82 to 84 and he worked on many of its important committees on be
half of the profession it's an honor for me today to introduce our our colleague Dr David Jones of Harvard University who will be giving today's Cassidy lecture Dr Jones is the a Bernard Ackerman professor of the culture of medicine in the faculty of Arts and Sciences and faculty of medicine at Harvard Dr Jones received his PhD in MD degrees from Harvard University both in 2001 the former in the history of science after an internship in Pediatrics at Children's Hospital and Boston Medical Center
he trained as a psychiatrist at Massachusetts General Hospital and McLean Hospital and then worked for two years as a staff psychiatrist in these psychiatric emergency service at Cambridge hospital Dr joins Dr Jones joined the faculty at MIT in 2005 as an assistant professor of the history of history and culture of Science and Technology and from 2004 to 2008 Dr Jones directed the center for the stud study of diversity in science technology and medicine at MIT there he organized several a succe
ssful series of conferences about race science and technology and in 2009 he was appointed as the McVicker faculty fellow mit's highest honor for faculty who've made sustained contributions to undergraduate education Dr Jones also taught as a lecturer in the department of global Health and Social medicine at Harvard Medical School where he was awarded the 2010 Donald O'Hara faculty prize for excellence in teaching in 2011 he left MIT to join Harvard Harvard faculty full-time as the inaugural a B
ernard Ackerman professor of the culture of medicine a joint position between the faculty of Arts and Sciences and the faculty of medicine the Ackerman program at Harvard University Fosters collaborations in the medical Humanities and social sciences across both campuses Dr Jones initial research focused on epidemics among American Indians resulting in a book rationalizing epidemics meanings and uses of American Indian morality since 1600. mortality rather excuse me published by Harvard Universi
ty press in 2004 as well as several articles he's also examined human subjects research Cold War medicine HIV and other sexually transmitted infections and the history of cardiac surgery his current research explores the history of decision making and cardiac Therapeutics attempting to understand how cardiologists and cardiatric cardiac surgeons Implement new technologies of cardiac revascularization This research is supported by an investigator award and health policy research from the Robert W
ood Johnson foundation for informed medical decision making and also by the National Science Foundation the first book from this work that Dr Jones has been doing is entitled broken hearts the Tangled history of Cardiac Care published by Johns Hopkins press in 2013 and it examines why it can be so very difficult for Physicians to determine the efficacy and safety of their treatments Dr Jones is now at work on two follow-up books one entitled on the origin of therapies which will trace the evolut
ion of coronary artery bypass surgery and the other on the history of heart disease and cardiac Therapeutics in India through his extensive historical research over the past several years on these topics and others Dr Jones has developed and articulated a profound appreciation for the value of historical content in medical education curricula a philosophy that he will share with us today please join me in welcoming Dr David Jones to the National Library of Medicine to deliver this year's James H
Cassidy lecture on this important subject one that interested Dr Cassidy as well making the case for history and medical education thank you [Applause] I'd like to thank Jeff and the staff of the National Library of Medicine for the invitation to come speak with you here today I'm a big fan of the National Library of Medicine for several reasons both because I've received a grant from the library which funds part of my research and second because the library has maintained its commitment to kee
ping and curating very well one of the most valuable collections for materials in the history of medicine any place in the world have now spent two days this week happily ensconced in the library reading room getting my hands on material that is relevant for my work in India and it turns out National Library of Medicine has much better collections of Indian Hospital annual reports journals bulletins then those institutions and themselves in India have so if you're doing the research on history o
f medicine in India you're much better off coming here to Washington than actually going to India to do the work itself When I Was preparing my slides over the weekend in advance of this talk my son who's now in 10th grade was looking over my shoulder and when he saw the title he said dad why are you going down to Washington to ask them not to take your job away why do you have to defend the importance of history of Medicine and so I explained that fortune I didn't think my job was at stake in t
his talk but I actually think that something much more important is at stake and this will sound like a surprising claim coming from a historian but that's actually what I think is at stake is the quality of Health Care and the resulting health of patients and I will attempt to convince you that both of these things could be improved if people who are practicing medicine and Health Care had a better understanding of the history of their field and so if you were to ask the broadest question does
the history of medicine matter you quickly realize that this is a question that Physicians have been arguing about literally for thousands of years you can find arguments about the history of the profession going back to Galen if not before and despite that it's something that most physicians in their daily work today do not spend much time thinking about history in any meaningful way if you were to ask a much more specific question does history of medicine matter enough to be included as an imp
ortant part of medical education again what you would realize is that for most of the history of medicine not just in the European tradition but in most East Asian and many other Medical Systems as well medical education was the history of medicine if you wanted to learn the practice of Western medicine or traditional Chinese medicine what you would do is you would study classical medical texts and that's how you would learn diagnosis and Therapeutics now obviously much has changed and as I'll e
xplain over the 19th and the 20th century history has lost a considerable ground from this high point in this role in medical education in 2008 the American Association for the history of medicine surveyed 174 medical schools in the United States and Canada and found that 98 of them had no indication of History anywhere in their curriculum another 19 likely didn't have any but I just couldn't verify that from the information that was available and of the 51 that did have some indication of histo
ry in the curriculum it was hard to find any information about what was actually involved and whether this curriculum was at all useful so given this compromised state of history of medicine in the early 21st century historians have been quite interested to notice what has happened in the field of popular publishing which is that two works in the history of medicine became runaway bestsellers over the past 10 years one of which won the Pulitzer Prize of course historians were quite Chagrin to ad
mit that neither of these Works was written by a historian of medicine one was written by an oncologist and one was written by a journalist but it was clear that the general public thinks there's something interesting and valuable to learn from reading or at least purchasing these books about the history of Medicine and historians especially historians who like like myself who work on Therapeutics have also been curious uh and interested in seeing over the past decade or so a series of discarded
Medical Treatments from the early 20th century have been revived in particular therapeutic contexts as I'll explain towards the end I think sometimes for better sometimes for worse and so for a variety of reasons in particular eras Dockers have recently begun to turn back to past Therapeutics discarded Therapeutics and search for possible therapeutic innovation and then the last place where you can see history of medicine alive and well and very much at work has been in the recent debates about
health care policy and in the I'm trying to remember exactly what year was I think this is in the winter of 2011 or 2012. I had the Good Fortune to have a have as a guest lecture in my class Larry Summers who was just back in Cambridge after two years as chairman of Obama's Council of economic advisors and he was talking about the inside scoop on the prospects for the Affordable Care Act so he was laying out the strategy as seen from within the White House and he said that everyone involved kne
w that the bill with the law was at risk because it had been pushed through Congress in such an unusual way but they knew well what had happened with the history of Medicare in the late 1960s which had similarly been a contested piece of legislation when it went through they knew that within several years the public had become quite enamored with Medicare once you give people Health Care they resist having it taken away and so the entire White House strategy in those first few years was to keep
the Obamacare alive long enough that if the Republicans did regain control of everything which they have the public would resist having it taken away and at least so far that seems to have been exactly what happened so there are all these cases where people are making good use of the history of medicine and yet it had largely disappeared from any kind of role in medical schools so today I want to explore this in more detail to explore the pro the obstacles and some of the opportunities part of t
his involves a quick review of the role of history in the history of Medicine and I want to talk about a conference that I hosted at in Cambridge in 2013 where I brought together met faculty who are teaching history of medicine at medical schools in North America for a brainstorming session which in many of the ways emulated a conference that had been hosted at the National Library of Medicine in 1966 almost Now 50 years ago and what I'll describe is that the participants in this conference emer
ged and convinced that history can and should be considered an essential component of medical knowledge reasoning and practice just like Anatomy biochemistry physiology or any of the other basic medical Sciences the historical analysis can offer essential insights into our understanding of disease Therapeutics and of Health Care institutions and these are things that Physicians must understand if we're going to have Health Care Systems that work as well as possible so again I suspect some people
will be skeptical of that claim but let me try to convince you now for centuries Physicians had turned to history to learn pragmatic medical knowledge Renee lenak who's often heralded as one of the first great modern medical Pioneers for his development of the stethoscope as a diagnostic tool wrote his own 1804 Medical School thesis on the continuing relevance of Hippocrates to Medical practice so as recently as the early 19th century famous Physicians Innovative Physicians were still turning t
o the past as their source of innovative medical knowledge or of relevant medical knowledge much of this changed in the mid to late 19th century as Medical Science increasingly turned away from history and towards the Laboratories as the source of new knowledge that you'll have people like Castor and Robert Koch shown here who become the heroes of a new form of medical practice and of course most of the work that takes place at National Institutes of Health is very much in the tradition of Paste
ur and Coke that turn to basic medical Sciences in order to make discoveries that will be therapeutically useful I'm not critiquing this approach obviously it's been immensely productive Health Care is much better now than it was in 1870 no one is going to argue that point but what happened was that Physicians turned away from these ancient texts and turned towards new laboratory knowledge as the source of future progress and in fact these scientists began to use history as a foil and what you w
hat you see especially in the early 20th century is people publishing contrasts between the wonders of new medical science as compared to the awful things that used to happen in the past so historical Medical Practice became The Whipping Boy against which modern Medical Science was contrasted and you can still see this if you look at popular medical writing now there's a every year or so a new book comes out that you know the 10 most outrageous things that past doctors used to do and there's eno
ugh of a market for these books that they often get reviewed in the New York Times and they sell pretty well even though many many and scores of these books have been published previously uh there's nothing Innovative about making fun of what doctors have done in the past now as practicing Physicians turn towards the laboratory and away from history people who were interested in history of medicine had to come up with new ways to defend the relevance of their passion for history William Osler wa
s one of the most famous proponents of the importance of history and medical practice at the time one of his colleagues at Hopkins Eugene Cordell who is president of the Johns Hopkins historical Club crafted a careful essay in 1904 where he laid out a whole series of arguments on behalf of the potential contributions that history could make uh you can read them here but the highlights are he said you know you can study history to understand what it is that we should investigate that historical I
nsight was the best knowledge against egotism air and despondency because it teaches us that much of what we have been confident in the past we no longer believe and therefore we need to have that he saw this as an antidote to hubris if you recognize the past people had made errors he'll be more likely to recognize the the errors that we are all likely making now uh he believed that potentially that history could be mined for overlooked discoveries that would have value again something that you
still see going on that uh present and he also saw an important role of historical teaching to foster a sense of professionalism and Professional Pride in medical students the basic idea here was you would teach medical students about these wonderful honorable Physicians who worked with that past and that would instill in the students some sense of the greatness and the worth of the profession and then they would behave better convinced of the essential importance of history of medicine Cordell
believed the history of medicine should be required at every medical school and taught as thoroughly as any other subject you had to have required courses with at least 16 or 20 lectures and he looked forward to the day when the quality of medical school would be determined by the quality of its historical teaching now if you actually look at the content of what Cordell was recommending what he really wanted was people to be taught a survey of the history of medicine in the western tradition goi
ng back from the ancient Greeks and following through to the present and he convinced it was that kind of survey of historical knowledge that would provide this essential value for medical students now obviously his vision did not come to fruition I'm not aware of any medical school in North America that is judged by the quality of its history of medicine teaching they're judged by many other factors instead but despite that his arguments continue to be made continued to be made throughout the 2
0th century and so you can go through literally decade by decade and find prominent medical Educators making a case for history that was often quite reminiscent of the case that Cordell had made in 1904 so before World War II you can see work by the leading historians of medicine Henry cigarest and Irwin akernet making the case for the history of medicine they both favored the argument that historical knowledge would provide an invaluable perspective on current practice then in June 1966 the Mac
y foundation and the National Library of Medicine hosted a workshop here at the National Library of Medicine they brought together uh faculty from a range of different institutions people who taught at medical schools people who taught more generally at faculties of Arts and Sciences senior people in the field very young people in the field at that time including James Cassidy he wasn't at National Library of Medicine yet he was working for NIH in Paris but was interested he came back for the co
nference and contributed actively and the person who was given the task of most thoroughly articulating the value of history of medicine for medical education was George Rosen very prominent historian of Public Health and again the arguments he makes are reminiscent of the arguments that are made by Cordell by tracing the history you could get a sense of how medical knowledge has developed the continuities between past and present you recognize that medical knowledge is always changing something
that will make you more open to the change that you will experience throughout your career it revealed the origins and then as a result the contingency of the ideals and values that doctors and patients hold which is important to understand he's he thought again it would give you valuable perspective when you'd realize how enthusiastic doctors had been in the past for treatments that were eventually discarded that would color how you would think about the enthusiasm enthusiasms as he said the t
he fads and modest trends that Afflicted medicine in the 1960s um and again you could Foster a sense of professionalism in its students now as you can see the conference produced a book that has not just the talks that were presented but also transcripts of the discussions that took place at this workshop at nlm back in 1966 and as you can see that if you if you look through there was vigorous debate about almost every aspect of rosen's presentation people argued whether or not it should be a re
quired history should be a required part of medical education could it be required if it were required what content would you teach there was very little consensus about any of these areas and then again these calls have continued in the generations since 1966. historians and Physicians also people who are trained as both Physicians and historians continue to push the case Joel Hal who's at University of Michigan emphasize the ways in which history can can help you understand the contingency of
medical knowledge and the fundamentally social nature of the medical Enterprise Jacqueline Duffin a historian at Queen's University in Canada emphasizes using history to teach humility towards Physicians so that to make them more willing to understand the the tall ability of Medical Practice Baron Lerner who's now at New York University argued that history would teach that scientific knowledge is not objective but it's a function of a particular historical time and place that social and cultural
factors influence both medical knowledge and medical practice and that the practice of medicine consists of humanistic interactions between clinicians and patients and thus should be conducted with dignity respect and compassion and these are just three examples of literally scores of Articles where you have people who are frustrated by the low representation of history at medical schools making the case to increase it and this isn't an exhaustive list and many other claims do get made but ther
e's a striking constancy to the core arguments over time that really goes back to Cordell in 1904. and the basic argument of all of them is that by teaching people history you can inculcate an an attitude towards medical knowledge and practice so it's not the historical knowledge itself that's important it's using history to inculcate an attitude towards scientific medical knowledge and practice again by revealing contingency it will Foster an openness to change and there was also an always an i
nterest in this the Humane and professional aspects of Medicine by teaching history it rehumanizes medicine in the face of scientific reductionism and demonstrates that medicine is fundamentally a social encounter between humans each embedded in particular social economic and political contexts and then also played a role by helping to socialize students into the profession you know one of the things that first year students often realize very quickly is that they are entering a profession that
will have an impact on many aspects of their life how they are considered in society the choices that they make how they interact with other people and often historian students will just stumble across this along the way historians have realized you could teach students to recognize this as in a self-conscious way and that can help ease the transition into the profession and also in a way immunize them against some of the undesirable aspects of the socialization that medical students encounter n
ow as historians were developing these Arguments for history of medicine they also recognized the many obstacles that history of medicine faced in medical schools and again there has been a striking constancy in these obstacles over time so William Osler complained In 1902 that the problem was just the men of the medical school curriculum had just become too crowded there had been too much Discovery in the past generation and all this new medical knowledge that existed in 1902 had made less room
for things like history and of course that problem is much much worse now than it was in 1902. Cordell bemoan the loss of interest in history uh he thought that everyone in the early 20th century was much too carried away with novelty everything that was new was good everything that was old was not good and this was the problem and again you can see traces of this alive and well uh today Henry cigarest uh with a wise Observer of Institutions recognized the basic problem uh facing historians of
medicine at medical schools was lack of time lack of personnel lack of funds and again that's a diagnosis that almost any academic would complain about in 2018. at the conference hosted here in 1966 Lester King was quite skeptical of George rosen's enthusiasm for the field uh for from King's Point of View the basic problem was that we cannot seriously maintain that it makes that history makes better doctors in any practical sense from his point of view the goal of medical school was to make peop
le better doctors if you couldn't prove and he didn't think you could the history would make someone a better doctor then there was no place for history at medical schools and have been a whole series of surveys over the course of the 20th century that documented the way in which history was losing ground as time passed Cordell had complained in 1904 that only three out of the 14 Schools he surveyed not a very large survey but only three out of the 14 had a course in history something he identif
ied as a shocking neglect an inexcusable apathy when the history of medicine Society surveyed the situation in the 1950s it found organized historical courses it roughly half at 47 percent of U.S medical schools the Canadians were doing much better with history in an organized course and 100 percent of seven medical schools in Canada but the authors of the survey acknowledged they really didn't know whether these courses were any good or not and these numbers have sent have tended to decline ove
r time as I said at the outset uh there are very few medical schools now that have any required history in the curriculum uh if where it does exist it mostly exists as an elective and the the octave offerings some of them are quite good but they're often quite idiosyncratic based on the interests of the person who's teaching them now one of the challenges the historians of medicine at medical schools have faced especially since the 1960 is new competition from Fields uh who you think would be us
eful allies but often have ended up as competitors for resources and that's medical ethics and medical Humanities both of which were new fields in the 1960s so both of these organized practices again obviously people have been interested in medical ethics for a very long time but a discipline of medical ethics first emerged in the 1960s in response to a series of crises or perceived crises in American medicine and health care uh especially with the Advent of mechanical ventilators in the early 1
960s you start to see people increasingly concerned about the overuse of medical technology and that new technologies had created a crisis of value in healthcare patients increasingly complain the doctors were no longer talking to them or examining them but we're increasingly relying on radiologic and laboratory diagnosis there were concerns about physician paternalism and debates about informed consent which was gradually emerging as the new standard of practice in the 1960s and then there were
a whole series of expose about research misconduct by physicians which did little to enhance the reputation of the profession one of the unifying themes in these critiques was that Physicians had somehow lost sight of that their patients were actually people who deserved to be treated with empathy compassion and respect so medical ethics promised a seemingly straightforward solution to these crises teach doctors to think more rigorously and self-consciously about questions of ethics and value a
nd behavior which is an excellent idea has become a huge Enterprise I mean NIH like every other institution has a major office that reviews all research protocols you cannot do human subjects research in this country without running it through an Institutional review board and having medical ethicists weigh in about what you want to do every hospital in this country now has an Ethics consult Committee of some sort or another that's available to provide consultation on questions of clinical pract
ice that seem to have been ethically charged medical Humanities also took shape in the 1960s it hasn't gotten the same kind of institutional embedding in hospitals and universities that medical ethics has gotten but it has gotten a traction more so in the United Kingdom and Canada than the United States but it is present in the United States uh the field again the exact form that medical Humanities takes varies a lot from institution to institution depending on the faculty that are there but has
been a mix of Ethics history law literature philosophy religion and the unifying theme for many medical Humanities programs is to help students understand questions of value and meaning not simply through philosophy and the way that bioethics might but through any of these humanistic explorations of medicine and Medical Practice and if you look at the many reviews that have been written of medical Humanities and try to understand what contribution are they promising to the practice of medicine
you'll find people arguing that training students in the medical Humanities can foster certain qualities of the mind it can it'll prove how you think about medicine and Medical Practice it enhances critical abilities flexibility perspective non-dogmatism again that notion of hubris about the contingency of medical knowledge and also Foster empathy and self-knowledge foreign as a result of the Advent of both medical ethics medical Humanities medical schools have now put those two groups in compet
ition with historians of medicine for space in the curriculum for faculty lines and also for for grant opportunities their whole series of grants that used to be available exclusively for historians of medicine whose mandate has now been broadened to include medical Humanities and medical ethics which greatly increases the competition for what is often a shrinking supply of these kinds of resources and you can see the impact of this in the most recent survey while 51 of the medical schools in No
rth America had some evidence of History 66 offered something in medical Humanities and 126 had a formal curriculum in medical ethics so there has been a sense certainly for the 20 years that I have been part of the profession of history of medicine that there was a crisis in the field and that we were losing ground on a variety of different fronts and the question was what to do about it so in 2013 shortly after arriving at my new job uh at Harvard trying to figure out what would be my mandate
in that position I started to do a survey in the field and came across all these proposals these arguments that had been made for the contributions the history of medicine could offer medical schools and universities I ended up not liking many of the suggestions it wasn't that I thought any of the past suggestions were wrong I just ended up thinking that these were not the strongest case that you could make for history and if you wanted to reverse the losses that the field had experienced you ne
eded to have a very strong case and if you're talking informally with several of my colleagues uh it turned out we all felt the same way and so I decided to host a workshop at Harvard in 2013 uh to try to figure out what we could do about this so I invited colleagues from medical schools throughout North United States and Canada to brainstorm about the challenge and possible solutions one thing we all realized and most of this had come from our experiences teaching medical students is that medic
al students are often very pragmatic either they're presented with a flood of Knowledge from their core faculty in the basic Sciences they're trying to figure out how to actively triage their time what should they be studying and time and time again the question that they come come back to is is this on the board exams which is sort of the pragmatic expediency that most first year medical students have to deal with some of them will be thinking about the underlying question will this help me be
a better doctor I think really the question that drives most of this is what do I have to do to get a good score on step one which is unfortunate uh and then Medical School Deans are often very pragmatic uh and that you know they have everyone in the world comes into their offices and wants more time more grants more space more laboratory for whatever it is that they happen to do and so the medical school Deans are always telling people no you can't have that and if you want to convince them tha
t they need to invest their limited resources in your Endeavor you have to give them a very concrete reason why it is that you will add value to their institution and saying that you will Foster humility amongst their students might be true but it hasn't proven to be a very compelling persuasive argument you have to do more and just promise that you'll produce more professional and students and students with a better perspective so as a result of these two days of arguments amongst ourselves uh
we ended up reaching a pretty good strong consensus amongst the group the historical analysis can contribute to medical education in exactly the same ways that Anatomy biochemistry pathophysiology or anything else can as a fundamental component of medical knowledge not as an attitude towards medical knowledge but as a fundamental component of medical knowledge itself and so our strategy was to develop a series of specific claims that we felt have self-evident plausibility and relevance and I'll
give you some examples and I'll show you the whole list so the first one the burden of disease changes over time a thorough understanding of disease includes knowledge of the non-reductionistic mechanisms that can account for these changes in other words the social determinants of disease and our feeling was there was no way you could possibly object to any component in that claim it is a clear empirical fact that the burden of disease does change radically and often quickly over time the top 10
causes of death now are very different than they were in 1850. uh and if you try to account for these changes you often end up with a very particular kind of explanations now this becomes a complicated issue in science policy and politics but for a variety of reasons institutions like NIH invest heavily in certain kinds of medical research especially research that emphasizes the molecular roots of disease and there are interesting explanations for why that has been the focus of effort here for
the past 50 years uh and as a result you know the scientists do work where the funding is the science journalists uh write about the work that the scientists are doing and as you end up if you were a random citizen reading the newspapers to try to understand what was important about disease you end up with a very skewed view of the world uh you'd think that genetics runs everything because that's the only thing that gets covered in American Science newspapers because that's where most of the res
earch funding is and so I've realized talking to both medical students and undergraduates that they often have these very bizarre explanations for how to account for the changing burden of disease where they assume that all must be genetics because genetics is all they ever hear about in high school or in college and I have I've even had students say with a straight face or present them with a graph produced by the CDC showing the increased prevalence of obesity in this country between 1970 and
the present depending on the population has doubled or tripled over the past 40 years and I'll say how can you account for that and the first explanation that most students will give is there must be genetic change in the human population and it said well why would you possibly think that uh and they can't answer that question because there is no reason you would think that there's been substantial genetic drift in the human population the past 40 years that would lead to a triple into the preva
lence of obesity it's just the genetics is a reflexive explanation for everything uh or if you were to say if you show them the very famous graph produced by Thomas McCune of the decline of tuberculosis in Western Europe between 1850 and 1950 you'll say well how can you account for the control of tuberculosis and people will say antibiotics because antibiotics are wonderful wonderful things and they get very good press coverage but turns out in that setting in Western Europe and North America an
tibiotics had very little to do with the decline of tuberculosis and so people have all of these mistaken Impressions about the factors responsible for disease change over time uh and that creates an interesting opportunity for historians to say well no your initial thoughts are not correct we can show that we need to think more seriously about what is it that determines the burden of disease experienced by a population and you can make very strong arguments and I'll come back to one at the end
uh the various social factors are much more important or public health interventions are much more important or at least equally important and if you are a medical student who's going to claim that you understand what disease is and how disease works your understanding of that disease needs to include these kinds of historical insights to account for why patterns of disease change over time because that will be very important that kind of historical perspective on decisions about policy and reso
urce allocation if you want to control a future burden of disease it's valuable to have a sense for why the past burden of disease has changed or another one that again is an empirical claim Health inequalities in both the burden of disease and in treatment access and outcome have persisted for Millennia history offers a central perspective about the causes of inequalities or possible solutions this comes out of in part the the first research project I had done that Jeff had mentioned about the
problem of Health inequalities between American Indians and the other populations in this country and there's now a over a 500 year record of colonizing Europeans recognizing that Native American populations had higher rates of disease than the earliest of these claims go back to Spanish colonists in 1510 but for 500 years now Europeans have always recognized that American Indians were sicker than the European colonists uh you can go through and read these accounts this 500 year history of What
kinds of explanations have been given for this disparity uh and they're very interesting patterns but the other thing you recognize is that disparity has persisted even as the burden of disease has changed and so when the Spanish and early English colonists in the 17th century were talking about the health inequalities they were largely talking about acute infectious diseases smallpox measles chickenpox uh influenza and others by the 19th century it was largely a function of tuberculosis and by
the mid 20th century it was largely a function of heart disease cancer and mental illness now for each of those moments for the smallpox for tuberculosis or for heart disease you can find people essentially making genetic explanations to account for these Health inequalities diabetes is the most famous example but for all of these major classes of disease some scientists has published them somewhere or claimed that this health inequality exists for genetic reasons and you can find an exactly par
allel literature about African Americans so again ever since African-Americans were slaved and brought here their health has been worse than the dominant white population in this country the health inequalities have persisted even as the burden of disease has changed and at any moment in that history you can find Physicians and scientists arguing that the particular disparity that was prominent at that time was genetic or hereditary in origin and when you bring all these historical claims togeth
er you end up in a very funny situation you realize that you have made an argument that Europeans are genetically resistant to every category of human disease compared to American Indians and African-Americans and when you frame it that way most people recognize that that's just a Preposterous claim again there's no reason to think that Europeans should have some kind of uber resistance to all categories of human disease compared to other European populations it's just not possible and it reeks
of for white supremacist uh rhetoric and so when you put it together like that people become very uncomfortable and they wonder how have they ended up with such an explanation that's patently uh implausible and intolerable in various ways well what's the alternative explanation the alternative explanation again is a social one the other thing that has persisted for 500 years for American Indians and for 300 years for African-Americans is persistent social economic inequalities those populations
have always been poor they've always had less access access to resources they have always been oppressed and along different axes and so that suggests a different explanation which is that the persistent inequalities and wealth and power are what are generating the inequalities in health regardless of what the prevailing disease happens to be so if you if the prevailing disease is heart disease it's prevailing diseases tuberculosis the populations that are worse off economically are going to be
worse off medically as well and I think that's actually what's been going on third case uh medical therapies and how their efficacy is determined change over time again that's an obvious Point uh be hard to do the math but I assume that well over 99 of all medical therapies ever tried have been abandoned the ones that remain are very small subset of of therapeutic effort good Medical Care depends on understanding of the changing values and evidence reflected in claims of therapeutic success uh t
here's obviously big business uh to be had in making the claim that this new therapy works that's a fundamental question that all patients ask their doctors will this treatment help me it's the fundamental reason for which people apply to Grants to aih I am doing research to find a treatment that will work so the question is well what does it mean to say that a treatment works many people have a simplistic intuitive sense it's like well it makes you feel better but as medical researchers have re
alized over the 20th century that's actually a very subtle and nuanced question there are many different ways to determine efficacy you can look at symptoms you can look at survival outcomes a therapeutic intervention often look very different from the perspective of the physician versus the perspective of the patient and there's something important to be gained by looking very closely at how people have thought about Therapeutics in a historical perspective and how they continue to think about
it today and you realize the various ways in which even something as robust as evidence-based medicine embeds within it a whole series of subjective value assessments that you need to understand if you're going to make progress in that Enterprise I'll give an example of this at the end and then a related clay medical Technologies exist as part of broader social systems history shows that Innovation is not always progress that technologies have unanticipated costs and consequences and why improve
ments are not always implemented again this is just a simple empirical claim you can choose your favorite example to illustrate these points but there are many valuable treatments that are not well utilized the most recent review of this question was published I think was in 2003 uh if a normal Internal Medicine found that Americans receive on average 50 percent of what evidence-based treatment should recommend that they should be getting I have asked the authors of that report to try to update
it has anything changed in the 15 years and they said the research involved in producing that study was so backbreaking that no one involved is willing ever to do it again so we're stuck with this 15 year old estimate uh but most people in health policy don't think that number really has changed that much A lot of patients are not getting the evidence-based treatment they deserve and unfortunately the flip side is also true an enormous amount of money is provided is spent providing health care t
hat isn't actually necessary for that patient at that time uh there are a whole series of subtleties of this but you know there was a report that got a lot of press last week showing that of all the patients who are prescribed narcotics uh 30 of them according to the medical charts had no basis in the chart for a prescription of a narcotic uh I suspect there are there were similar things going on but a claim that medical technology is overused uh is not a controversial claim in this country and
again history can do much to understand sort of show why this happens and what you can do about it so we ended up coming up with 13 of these short one-line claims and the idea was you could you could take any of these claims go to go to a dean and say look this is what history has to offer and to phrase those claims very carefully there's really no way they can say this isn't true or this isn't relevant and if you were armed with a series of claims like this you'll be able to be much more persua
sive and you can make a much better case whether to your Dean or to the students that you're trying to teach and so four of us got together and wrote up our results and published a couple years ago in the Journal of history of Medicine and again as I've been saying our claim here uh is that the specific arguments you can make about the history of medicine demonstrate the undeniable value of History to Medical theory and practice history does not just convey an attitude towards medical knowledge
recognizing contingency antidotes towards hubris instead historical analysis uh alongside molecular biology or pharmacology makes fundamental contributions to our understanding of disease and Therapeutics so if you were convinced by this the question is well how would you actually implement this in practice what might it actually look like so let me give you a couple examples of the kinds of stuff that we do in the curriculum at Harvard Medical School we're founded Harvard Medical School does no
t have a course in history of medicine so if you were a surveyor who was looking at the curriculum you would conclude that Harvard is the place that does not have an organized course in the history of medicine that'd be a misunderstanding of how the curriculum Works uh I was well positioned during the most recent round of curriculum reform and so I was able to embed history or historical perspectives in a series of places into the curriculum in ways that aren't advertised as this is the history
of medicine lecture uh but get people engaging with these questions and thinking about them in a serious way and it's really not that hard to do so one thing that you know first year students often realize is the medical profession and also especially the teaching faculty at most U.S medical schools is not as diverse as the rest of society uh since the 1990s most medical schools in this country have been at least a 50 50 male female split many medical schools have had a majority of female studen
ts now for a generation many medical schools have made great progress diversifying the student body so now at Harvard Medical School the class the entering class you know for decades now has been more women than men more non-white students than white students and yet The Faculty especially the teaching faculty is a largely a group of white men which raises an interesting question and if you were to look at Department chairs at hospitals it'd be a similar situation incredible diversity amongst me
dical students interns residents and Junior faculty very little diversity at the senior ranks of Hospital departments foreign observation uh the question is well why does it exist what can you do about it and it's a great topic for historical analysis uh Harvard Medical School has its own sorted history when it comes to both race uh and gender The Faculty voted to admit African-American students for the first time in the 1850s and that was blocked by the students uh the white students felt that
having black students in the classroom would diminish the degree that they would receive and the faculty caved in to student pressure the medical school repeatedly wanted to admit women but was blocked for a variety of different ways first by students then by faculty it was only during World War World War II that Harvard Medical School finally meant co-ed and only because they could no longer fill their classes with men because all the desirable men had been drafted and were in war so the only r
eason Harvard Medical School went co-ed was because of the contingencies of World War II the irony there is a decision to do it was a day before D-Day and people will joke if the committee meeting had been postponed a week they might never have done it because if they had known that D-Day was as successful as it was they might have realized that they could just hold out one more year they would have the men they needed and would not have had to admit women hard to know what would have happened b
ut those kinds of counterfactual questions can often be fun for discussion uh another one that has always been on students mind uh why do we have such a bizarre Health Care system in this country uh why is the United States alone of the wealthy countries and not having universal access to health care uh again a great topic for historical analysis uh if you want to approach Health policy without wanting to bang your head against the wall one of the best things to do is to approach Health policy t
hrough the perspective of History to understand why we have the system that we have what are the various interests that have been uh have an influential they're great sources that are available now to document the history of healthcare policy one of the ones I like to use most of the students is this LP produced by Ronald Reagan back before he was governor of California he was hired by AMA in a series of Shadow entities to record a 10-minute uh audio recording against socialized medicine has now
been digitized it's available online it's worth a listen if you haven't heard it it's really an amazing piece of political rhetoric it feels very relevant today because many of the arguments he made 50 years ago continue to get made against Universal Health Care foreign if you're interested in this question of you know what determines the uptake of new therapeutic Innovations there are a million case studies that you can use one of the ones that's most alarming for students is the history of an
esthesia it's fun for us because this is a bit of local history as many people are aware the first met surgical demonstration of ether anesthesia was done at National Hospital in 1846 uh and if you look at what happened over the next 10 years there was very quick enthusiasm news of this spread to Europe very quickly it was the first case of a medical intervention Innovation crossing the Atlantic Ocean from west to east obviously now has happens all the time but this is the first thing that Ameri
cans discovered that was picked up by Europeans part of the reason the anesthesia was picked up so quickly in Europe uh is that these drugs had been well known amongst medical students for 50 years ether and nitrous oxide were both used as party drugs by medical students in the first half of the 19th century it just never occurred to anyone to use them for their patients as part of surgical anesthesia so understanding that half of the story is both fun and alarming for the students and also if y
ou look at the uptake even though anesthesia became popular in some sectors very quickly it wasn't true everywhere and so anesthesia was not used at Pennsylvania hospital now the University of Pennsylvania until 1853 so there was a seven year Gap after ether had been demonstrated in Boston before it was ever used in Philadelphia uh the explanation that in part has to do with the long-standing medical rivalries between Boston and Philadelphia but it's a very interesting story to explain how and w
hy something like anesthesia was or was not used in different times in different places and you can also do much with history as part of an exploration of medical ethics we now have a very elaborate processes in place that govern research especially human subjects research most people who do medical research you know are filled with Dread when they think about irbs and the annual certifications that you have to do and everything else and the question is why do we have the system in place what va
lues are embedded in it how could it be changed what can we do to make this uh more burdensome or you know if you recognize the reasons why this bureaucracy was imposed it often makes you more tolerant for the bureaucracy that exists and again they're terrific cases of various research scandals and non-scandles over the 20th century to get students to think seriously about the kinds of values that are embedded in human subjects research foreign history can also play a role in thinking about medi
cal research and practice not just these questions of what you want to teach students so as I said you know over the past decade or so several treatments that had been dabbled with in the early 20th century and then abandoned have been revived in certain quarters which raises obvious question is this a good idea now no one stops to ask the historians do they think this is a good idea they've gone ahead and done that and so questions well had they gotten the historical consult with the outcomes h
ave been different and the answer depends on the cases so one of the ones that has come up recently has been zero therapy so zero therapy is using antibodies therapeutically against infectious diseases now obviously one of the Great accomplishments of the 20th century Medical Science was the development of antibiotics and antivirals that have led to I don't know the right adjective views not the total control but the substantial control of infectious diseases and the potential for near total con
trol is these Technologies were utilized as widely as they could be between antibiotics immunizations antivirals we have tremendous power over many of the Great infectious diseases but by the late 20th century a series of problems had materialized it has been difficult to develop antiviral medicines for a variety of reasons viruses are much trickier to do than bacteria and so there are many great viral pathogens influenza Ebola and others for which there's not a great treatment as there is now f
or HIV and many antibiotics many bacteria have been busy developing resistance to antibiotics I was at who archives last week and they had a big placard out of the main entrance our time with antibiotics is running out which is obviously a fearsome thing to worry about well the question is what to do uh all of these recent developments have led to a Resurgence of interest in the early 20th century therapeutic system with zero therapy and the idea as it was developed especially in the 1920s and 1
930s was to collect antibodies from people or other creatures who had been infected by a pathogen and the way this was operationalized by most public health departments was to have large Stables of horses or large collections of rabbits who you would infect with a pathogen they would then develop antibodies you would then harvest the antibodies from those rabbits and horses and use them therapeutically in humans it's obviously a much more cumbersome system than giving someone an antibiotic but t
urned out for certain diseases in certain contexts it was a hugely effective approach you know pneumococcal pneumonia had been considered one of the great scourges of early 20th century uh medicine uh William Osler named it the captain of the the men of the captain of the men of death was often described as an old man's friend because if he were sick and chronically ill you know one of the things that you could hope for that you would have an easy death from a rapidly Progressive bacterial pneum
onia uh but with the Advent of type specific antinomial stero therapy produced in a very particular way in the early 1930s in the 1920s 1930s you had very good control of pneumococcal pneumonia in hospitals doctors were so pleased with the power of serotherapy in the setting that when the first Alpha Drugs and then even when penicillin became available in the late 1930s 1940s there was skepticism about whether these drugs were needed uh and so if you look at some of the early Trials of antibioti
cs they were often done in addition to serotherapy because Dr celt it was unethical to withhold serotherapy which you knew worked from patients while you're testing these newfangled antibiotics and so these drugs can work very well in the right setting and if you do careful historical analysis there's a great book about this by my colleague Scott Podolski again the the work for this book was funded by one of the nlm historical research grants you can understand what is involved in getting zero t
herapy to work well it's not a simple thing to do but with the right design of a system and the right resources zero therapy can work really well when with the outbreak of Ebola in West Africa uh many of the therapies that were tested then and since have essentially been serotherapy collecting antibodies from people who had survived Ebola and so this kind of approach remains alive and well in certain areas that my own research is just that recently has been about the history of cardiac Therapeut
ics or in the early 20th century coronary artery disease became the leading cause of death not just the United States but now worldwide and every country in the world except in some patches of sub-Saharan Africa coronary disease is now the leading cause of death over 10 million deaths a year doctors and surgeons obviously were quite interested in developing treatments for this many of them recognize the disease as a problem of supply and demand as atherosclerotic plaques form in the coronary art
eries it impairs the ability of the vascular system to provide blood and oxygen to the heart and when you have a heart that's dealing with an inadequate supply of oxygen you can get angina chest pain or you get heart heart attacks or sudden death surgeons tackle this problem with Incredible creativity and Innovation trying to figure out how to do one of two things either reduce the heart's demand for oxygen which involved cutting the sympathetic nerves or removing the thyroid gland trying to dec
rease the overall metabolic burden on the heart or trying to figure out ways to provide new blood supply to the heart and again I said they were very creative in how they would do this they would take arteries from parts of the body and embed them into the wall of The ventricle itself they would wrap the heart with various tissues whether muscle or lung or spleen or momentum and they would do things like they would sprinkle the surface of the heart with asbestos in hopes of producing Scar Tissue
the idea being that blood would flow through the scar tissue into The myocardium and provide a significant new supply of Heart of blood to the heart as one skeptical editorialist in the Journal of Medicine wrote in 1957 the implantation of tissues bearing vascular the plunging of a pulsating and bleeding artery into myocardial tissue the creation of pericardial adhesions and attempts to augment by irritating epicardial substances intercornary anastomoses have placed The myocardium in a class by
itself as an object of surgical assault now all of these treatments can be high on people's lists now of like the craziest things that surgeons did in the 20th century but I think that's amazing about this if you go back to the literature at the time surgeons often publish very robust outcome studies of these procedures these surgeons were often very careful researchers they were very Savvy about Placebo effects they were very Savvy about how dangerous it could be to rely on a subjective assess
ment like angina if you're trying to figure out whether or not a patient has survived and so they tried very hard to produce objective evidence of the efficacy of these interventions and so I have a video that I want to show you uh of a woman who was treated by Claude Beck a prominent surgeon in Cleveland and so what what you'll see here is the patient before surgery describing her her how she's feeling you'll see a couple of she and her husband describing how improved she was after the surgery
and then I have a clip of her interoperative video so you can see what the surgeons actually did and these have both been excerpted the actual video itself is much longer I have pain in the chest and I am short of breath exertion brings on pain I am limited to only Lighthouse work my operation was done one year ago I have had an excellent result I have no anginal pain and take no medication whatsoever I do all my own housework since the operation my wife is a new woman the Gloom of weakness pain
and suffering was always present in our home now a new life has been restored to her as well as to me and my family she enjoys social events she likes to dance and she likes to wear pretty clothes again she lives a normal life the entire surface of the heart is gently abraded the coronary sinus is narrowed asbestos powder is sprinkled over the entire surface of the heart two-tenth gram of asbestos powder is used it is a mild inflammatory agent and produces collaterals now obviously much has cha
nged since the early 1960s when this video uh was created and this was before asbestos was recognized as a cause of mesothelioma and asbestosis so the cultural valences of asbestos were very different than than now um and if you look listen carefully to what the husband and wife were saying uh many of their claims of efficacy involve very specific domestic expectations of women you could you could generate you could determine the health of a Woman by her ability to do housework to host cocktail
parties to wear fancy clothes some of my students from Australian this video have said when the husband says she likes to wear fancy clothes again is that code for saying they have resumed sexual relations uh it may be there's no way of knowing but all these things are involved very coded language uh and this is just one example I could give you example after example after example of very specific and sometimes compelling efficacy claims being made about treatments that we would now consider biz
arre toxic totally pointless and funded by National Library of Medicine I'm nearly finished a book that explores the history of this and what you can learn about the Therapeutics by taking seriously some of these strange surgical procedures that were popular before before the 1960s so you can imagine my surprise in 2015 when the Newland Journal of Medicine published a randomized clinical trial sham controlled of one aspect of that procedure that you just saw so what Beck did during that operatio
n was he stripped the epicardium off the heart sprinkled it with asbestos and then put a constricting band around the coronary sinus that was a that coronary sinus restriction was something that had been tried in the 1930s the 1950s it never made any sense exactly why that would work so the coronary sinus is the vein that drains The myocardium so blood comes into the heart through the coronary arteries it goes through capillaries gets gathered from the capillaries from the coronary sinus and the
n drains back into the atrium of the heart and so it wasn't clear why restricting flow through that coronary vein would treat coronary artery disease but all sorts of intuitions many of the ideas were a bit half-baked it was tried uh eventually they realized it didn't help and it was abandoned for reasons that aren't totally clear to me that idea was revitalized in the early 2000s not to do it surgically but because now you could do it with a cool catheter-based technology and so you can see her
e uh they have this neat looking hourglass shaped coronary stent not a coronary artery set a coronary vein stent that you can put in through a catheter and achieve a partial restriction of the coronary sinus it was a cool new technology that allowed them to do more easily something that surgeons had tried to do through heart surgery in the past that I was asked by the Journal to write a commentary on this to accompany this article when it was published uh and it was very tricky to do because the
journal had decided to publish this randomized clinical trial uh which in a way they thought this thing made enough sense to make it worth publishing the Newland Journal of Medicine uh and I was coming out this as a historian uh thinking like this was the stupidest thing ever but I could I couldn't say that because if I said that that would then be casting doubt on the Judgment the editorial Judgment of the journal that had decided to publish this trial so it was a very delicate balancing act a
s I was trying to write up my commentary on this but just because you can do something more cleverly now than you could 50 years ago doesn't mean it's a good thing to be doing uh the question that they should be asking is well did this ever make sense in the first place and if it didn't make sense in 1950 it doesn't make sense now so you shouldn't do it even though you have this cool new hourglass shape stunt that's probably making someone a lot of money uh and sure enough you know now there are
a whole series of articles about this coronary science reducer that have been published and if you look at the sections of these papers where they try to explain the physiological rationale it's completely incoherent uh they really have no idea why this works and many of the claims they make uh are internally inconsistent with each other but they say but but it works if you look at the Patients the patients report feeling much better their angina is relieved uh and as someone who's we're writin
g a book about the history of treatments for coronary artery disease the most obvious answer from the history of these treatments is that anything you do to a person will relieve their angina that has been shown literally thousands of times over the past hundred years and just because the treatment reduces angina doesn't mean it's actually good for the patient it's a complicated issue but anyone doing this research ought to know the problems with relying on subjective assessments of coronary art
ery disease and yet now there's this whole literature uh and a device industry making these devices that's based on what any historian would recognize is an unreliable claim so I hope the bottom line here is clear there are many ways you can make the case for why understanding the history of medicine can offer essential insights into the theory and practice of Medicine there's important knowledge about both disease and Therapeutics that is best taught through history and you could make similar a
rguments about health care policy or ethics or many other areas there will of course be skepticism and resistance you know how could history be as important as biochemistry or pharmacology or anything else but just because there's resistance doesn't mean that you should abandon these goals of restoring history to a useful place in the medical curriculum it just means that historians and Physicians interested in his story history need to work carefully to strategize and deploy the best arguments
to make the case for history well and if you do it should be possible to find ways to reinsert history into the medical school curriculum in ways that I think in the long run both Physicians and their patients will benefit from so I'm happy to take time for questions [Applause] yes I'm supposed to ask people to come up to microphones we have microphones excellent so how did you structure your commentary for the uh coronary vein stents the I I had I had a whole lot of very specific language in th
e first draft and when I went back and forth with the person who edits the perspective system section which is clear that I wasn't going to be able to be totally direct so what I end up saying is I it's mostly a historical piece about the efforts of Claude back the surgeon who produced those videos to say this is what he tried these were the obstacles that he had uh really the key issue in the end was that there was no credible physiological rationale for why the coronary sinus restriction ought
to work and mostly leave it up to the imagination of the reader to fill in the blanks and be skeptical of it at present uh it's very hard to know that whether those sorts of interventions have any efficacy uh when I did a recent search I was quite pleased to see uh that there was a there was a more recent say so I was commenting on a 2015 study there was a big study that was published just this past April again showing how wonderful this treatment was and how well it relieved people's angina an
d some cardiologists who's a blogger wrote a blog post about this 2018 study uh where he said this makes no sense at all and then cited my perspective uh so at least someone read between the lines so yeah thank you so much for your talk it was just really rich and wonderful um I have a question the the some of the early examples that you gave about the claims what claims you could make and sort of the why behind why we are where we are I'm curious if you've um partnered with some of your behavio
ral Economist colleagues those who are you know getting into this sort of the sense of a nudge or or to change because you clearly could present the evidence and kind of almost lay a pathway out for impact on present day particularly in public health and so collaborate with them to try to figure out ways to actually be more persuasive in making this happen be more persuasive or put the the nudge in place that moves people in a certain direction without having to even particularly persuade them y
es so so I I so I haven't that's an interesting question the you know if you wanted to go forward to try to make the transition so we published this article on the question of what's the efficacy of publishing an article um I think we'll say not very much you actually have to then follow through and to to you have to work harder to actually make your ideas or to put your ideas into action so how would you figure out the best way to put this into action uh no it's a tricky thing the as I said the
medical schools are facing a zero-sum game in terms of the number of hours that you can expect students to do work uh there are many complaints uh from undergraduate and Medical School faculty that students study skills just aren't what they were 20 or 30 years ago so it used to be when I was in college you could put people in a lecture and expect that some of them will learn something from that lecture now whether or not they actually did it's not it's not clear but much pedagogy was based on
the fact that you could put someone in a room for an hour talk to them and have them absorb something of what you said or that you could ask them to to read something like read a book and then learn something from that and it's quite clear from talking to students as I said both undergraduates and medical students something has changed uh I think has changed for the worse and so a lot of students will now say you know if they go to election they just tune out they can't they're unable to listen
to a lecture uh for an hour uh much of that has to do with you know 30 seconds into the lecture they check their social media status and once that happens once the lecture is ruined for them uh and if you look at course evaluations they will often say uh any reading longer than something two pages five pages eight pages should be dropped from the syllabus because if someone can't express their ideas in that length it's not worth reading which is a very strange attitude towards knowledge and they
'll say well you know all you always require too much reading it took me five hours to do the preparation that's just not realistic So and I've had students say it took them five hours to read 30 pages uh so then I'll sit them down and say like what on Earth were you doing for five hours like if you had read this out loud and slowly uh it wouldn't it wouldn't have taken you five hours uh and so the it can be very difficult to figure out against when you're dealing with that kind of resistance wh
at can you do uh our approach was to do this subtly you know there are great books that historians of medicine have written you can't ask medical students it's even hard to ask undergraduates to read something a book length uh the it's clear that medical students are totally interested in doing uh case-based approaches as developed repeatedly by medical innovators that you know case-based approaches can get through student thinking in a variety of useful ways and so that's the option we've gone
for we present them with a series of cases the case asks there's a question you know why is the HMS faculty so undiverse and then it gives them the chance to brainstorm and the question is well then how do you equip them with the knowledge needed to have a useful brainstorming session about this and we've ended up sort of custom writing a whole bunch of curricular materials which I'll be happy to share with anyone who's interested just email me and I can send you what we've done uh trying to nav
igate this line between the impaired attention spans and the need to provide knowledge as a basis for informed discussion uh and I don't know if we're totally successful uh but again I think by doing it subtly yeah you know which is again with the behavioral Economist would say that say you know if you want people to choose fresh fruit at a cafeteria you know put it near the cash register presented in an appealing way have that set as the default so we were able to embed historical content essen
tially as the default in different places in the medical school curricula and present it in a palatable way and that has been successful that it's not a answer that can work everywhere two summers ago I was part of a delegation of Faculty from the U.S that went to talk to Medical School faculty in China so China perceives a massive crisis of medical professionalism similar problems in India the very high rates of assault against doctors China has decided that one of the solutions to the crisis o
f professionalism is to mandate teaching in medical Humanities at all medical schools in China which I'm supportive of I'm not sure if that's going to solve the problem I think it's sort of a good idea of being done for the wrong reason but the question is well how do you do that they don't have the faculty required to teach medical Humanities at every medical school and some of these schools are quite large so I gave a talk similar to this one described what we had done and the guy said well co
me to me afterwards and say well I have a problem I'm responsible for teaching medical communities at my medical school I'm the only person on the faculty who's going to do this and we have a class size of 2 000 students uh how can I teach you know because all the teaching we do with the history at Howard medical school is small group discussions uh he said I can't do a small group discussion with 2 000 students I have to do lectures how can you adopt this approach to lectures uh you know at whi
ch point my brain just seized up at the thought of having to try to teach anything in the lecture format to a group of 2000 students um and so you know all of these things that that whatever nudges you're going to do have to be done locally with awareness of you know what resources you have access to what opportunities do you have in the curriculum uh what kind of Dean do you have and what kinds of arguments will be persuasive to that Dean or not uh and so and you know all politics uh is local a
nd you just have to to be Savvy we've been quite lucky in the current uh uh Administration Harvard Medical School the dean of medical education is a philosopher and ethicist so he's very sympathetic to all this and the dean of the medical school is a stem cell researcher uh who over his career has recognized that ethics actually has an important thing to say to medical researchers and so we have the Good Fortune to be in a very sympathetic environment that's not always going to be true the two d
eans ago was completely uninterested in any of this stuff and so the situation we have now is good but I'm aware that it's not going to last or it's at risk of not lasting forever yeah yeah thank you a great great talk thank you very much um I'm wondering if in in this conversation about how much is on the plate of of medical students in medical schools and and what bandwidth and time do they have to add a discussion of history is is there a possibility that looking at the whole academic career
of of a doctor that they have they have four years before medical school when they're able to to take a very broad broad brush on their experience so certainly they're pre-med and and they're taking pre-med courses but generally as part of their University study they're required to take courses in English and writing courses in history courses in in other disciplines that in a lot of ways could add to their efficacy as a doctor so has there been any thought to that as well yeah and and then the
other place the question that comes up is uh what about postgraduate medical education oh and so yes so if you're going to try to improve the knowledge base of practicing Physicians you have a huge sort of series of different opportunities to try to do that uh and the the appeal of doing it at the medical school well it was that's of all these opportunities that's the most regimented one you know the wamc keeps pretty close tabs on what medical schools are doing uh in theory uh they have the pow
er essentially to throw a switch and they could they double ANC could mandate history medicine teaching they've essentially mandated medical ethics teaching now all medical schools teach medical ethics and so it's one of the very few places in American Education where there is that kind of command economy uh if you could do it the current Administration wamc is actually quite sympathetic to this the problem is if they were to put a mandate would cause a problem for the majority of U.S medical sc
hools that aren't staffed to do it uh so that last time my colleagues had a long discussion discussion with the leadership at wwmc the issue wasn't whether or not this was a good idea they just said you know of the 180 some odd medical schools in this country only about 30 of them could do this well and so we're not going to get put a mandate on medical schools to teach history when they have no historians on their faculty now there's also leverage on the pre-med curriculum and that everyone has
to take the MCAT test in 2015 the MCAT now requires a section on uh social Behavioral Sciences uh and again on sort of a grab bag category has created a problem at colleges uh you know the students now say okay I know that if to take the MCAT I need to take organic chemistry General chemistry physics biology where's the course that prepares me for the social behavioral section of the MCAT many colleges have created one and it's a hodgepodge course that does a little psychology a little sociolog
y a little philosophy a little history uh many schools first don't or sort of don't like the idea of teaching to the test so don't want to create a course specifically to train students to take a standardized test just because they feel that's wrong in some way uh or you know they that would require getting a sociologist a psychologist a historian Anthropologist and ethicist somehow to agree on what it is that they're going to teach which is possible but not easy uh and so as a result the studen
ts then sort of choose the source Smorgasbord of activities trying to figure out what to do and then they just buy the review book which tells them how to study for that test so there are great opportunities to do this in undergraduates um you know and various schools have dabbled so Sinai has a program uh where that makes it easier for people who are doing non-science undergraduate careers to get into medical school and now they've been doing outcome studies to show that the people who have non
-traditional backgrounds do just as well in some respects have higher quality of life the word is getting out the I teach a undergraduate medical ethics and history course of course it takes a historical approach to Medical ethics and that recently the enrollments had ballooned which was useful and gratifying I was talking to students about why this had happened uh and the answer that came back was that many medical school admissions committees now are asking students ethics questions as part of
the interview process based on the idea that somehow if you ask people ethics questions you get a sense of they're thinking and moral fortitude or something uh and so the word on the street at Harvard is that my course is a good preparation for Medical School interviews well I'm happy to have good and big enrollments as like that's not the reason you ought to be taking this course to prepare you for this very artificial environment of medical school interview uh but certainly undergraduates hav
e much more bandwidth uh and I mean since I go back and forth between teaching medical students and undergraduates I can actually teach the undergraduates a much more sophisticated version of all of this than I can teach the medical students and so this weird thing to be teaching the more advanced professional students the watered-down version of what I teach College freshmen but you know that's how it goes the within the medical school there's interesting about you know should you teach student
s in the first and second year before clinical work or should you teach after clinical uh rotations the I'm increasingly in favor of trying to get this kind of teaching done after the clinical rotations uh you know telling first-year students that the Health Care system is broken you need to understand history so you can understand it doesn't resonate with them but if you see students after 12 months of intensive exposure to Medical bureaucracy they are then much more interested in these questio
ns or if you talk about you know a problem like non non-compliance in the ways in which Physicians often wield non-compliant as a judgment against their patients in a way that disrupts patient doctor relationships first year medical students will say I will never be judgmental of my patients uh security medical students no longer have that confidence uh and then there are also opportunities to do it uh for postgraduate medical education teaching at medical conferences of various sorts there are
lots of opportunities yeah so in one of the cases you brought up you mentioned if they had gotten a historical consult so can you give us a sense of you know how often historians are consulted in ongoing biomedical research is this something that happens my sense is it never happens yeah or it may have happened I'm just not aware of any uh examples that trying to think is that really true some of the people who were involved in the serotherapy stuff were aware that there had been a prior history
of serotherapy uh but I don't think their engagement the history got went any deeper than sort of reassuring that this happened uh that it created sort of a market for the historical knowledge and so uh when serotherapy started getting discussed in the midst of the Ebola epidemic in 2015 uh one of the editors at annals of internal medicine Deborah cotton who's an amateur historian said serotherapy I know someone who knows something about this let me call Scott padalski and so she had Scott righ
t essentially a cliff node version of his book which was published in animals and that got widely picked up uh it was covered in the New York Times uh and so there are cases when the people have gotten there on their own they've realized that there's an opportunity for historical knowledge and that has that historical knowledge then got traction but again it was done after the fact I can't think of it when it was done prophylactically um and in my interactions especially with Interventional card
iologists to some extent with cardiac surgeons for a variety of reasons there's a lot of resistance to engagement uh with the history of these fields in part because they see any kind of historical analysis as a critique and you know and it's very easy as a historian to be to be critical of what's happened in the past and most of what passes is historical analysis is a critique of what went wrong in the past in order to do something better in the future uh and so I can understand why current pra
ctitioners of those fields often have a defensive response to that uh the the depth of the defensiveness that I've seen in Interventional cardiologists is really stunning um I once gave Grand rounds at one of the hospitals in Boston uh that the title of the talk had overuse and angioplasty both words appeared in the title not adjacent but they were both in the same title uh and even before I gave the talk I got about 20 emails from one of the Interventional cardiologists uh writing a critique of
the talk that I had not yet given and initially I tried to engage with them in a conversation and this was before uh fake news had become a big thing uh I mean I have a much better understanding of this conversation now than I did at the time I tried to establish a historical common ground so I said look here are four things I think we can agree on uh that there have been controversies about the appropriate use of angioplasty there have been accusations of financial conflicts of interest and th
ere are a couple of other things both of which are just straight empirical comments it's not a question of interpretation but there there has been controversy about these things he wouldn't even accept those four claims there was Zero common ground to have a conversation uh about this uh which to me is really really interesting uh you know why are these uh uh groups so defensive about this kind of History uh I once got Chris Heisman A Very senior cardiac surgeon at Mass general who said look I u
nderstand why you're critiquing things that cardiac surgeons did in the 1960s like when open heart surgery got going in the 1960s uh surgeons paid very little attention to the neurological complications of heart lung machines which it turned out at the time were substantial and they're interesting things to be learned by studying that history and so you know as I wrote in one of my books you know there was this long period of time in which doctors were not paying attention to the complications o
f these devices and it's likely the fact that patients were harmed as a result of this uh so the surgeon said well by telling people now that surgeons did a bad thing in the past what you have to understand is that people often aren't very sophisticated in their historical thinking people are going to mishear your critique of past surgeons as a critique of current surgeons they're going to choose they're going to be scared away from surgery and they're going to die as a result of your historical
work uh and the argument basically was uh you shouldn't bring up bad things that happened in the past because they could scare or confuse people in the present uh and if you believe that argument there would be no history like you and I put out this quote that this is a quote written in 1639 uh about the value of History uh that was quoted by Osler In 1902 is one of his reasons why history was so important uh and the obviously the language is uh a bit foreign but the uh the basic idea here was
that by studying history you can learn from the mistakes of the past and get more wisdom and experience that you would have based on your own life experiences I'm totally convinced by that and so I was horrified to hear the surgeon saying it's best just to ignore what happened in the past uh because the past can harm the present in some way uh and I'd say I said well I just have a diametrically opposed vision of that we need to understand the mistakes in the past so that we can do things better
in the present and I had made no progress at all trying to convince him and so as a result you know the uh the I think most people now has said there are very few places in which history would be obviously relevant to a biomedical researcher uh and I just don't think that's true and I think if people if historical training of doctors or biomedical scientists was better there would be more recognition the ways in which there is a common dialogue that could be had people might consult people bette
r uh you know and it would many people would benefit one example I think of a successful collaboration back and I think it was after the fact it was in the 1980s as the AIDS epidemic was starting to get into a full swing uh the person who became my advisor Alan Brandt was the historian who had just finished a book on the history of syphilis um which was published in 1982 realized that he was well as a now historical expert on venereal disease control and sexual Moors in this country he had he wo
uld have something to say about the AIDS epidemic uh and he was quite successful in getting traction he was able to publish in science the American Journal of Public Health he gave talks at most medical schools in the country about the historical lessons of syphilis to HIV uh things like uh premarital screening is pointless because the population who submits the premarital screening is not the high-risk population for either syphilis in 1910 or HIV in the 1980s he now has to back away from some
of his arguments at the time he said well look when people when penicillin was developed people thought the penicillin would be a cure-all for syphilis it turns out to have been much more complicated than that syphilis persists syphilis has actually been on the increase over recent decades despite the Advent of Curative antibiotics his phrase was there is no magic bullet these things are complicated social epidemics a single solution technological solution isn't going to be a huge asset so he sa
id the same thing would be true in HIV so you know people are going to look for magic bolts for HIV but they're just not going to be that effective but HIV is a case in which protease Inhibitors were really really effective uh they haven't solved the problem uh the incidence of HIV has been totally stable the U.S has 50 000 new cases every year now 50 000 new cases every year in the 1990s so there's been no decrease in incidence in HIV in this country for 30 years but it's very little mortality
and so that is a case where the historical consultation made sense at the time in retrospect probably wasn't totally accurate but now you could write a revised one you know what are the conditions in which a magic bullet-like therapy works or doesn't work um so I think it's a missed opportunity there are lots of good things that historians could offer if they were able to have good conversations with the researchers but are many sources of resistance excellent so if there are no more questions I
'm happy to stick around and talk to anyone who wants to follow up otherwise thank you for your attention [Applause]
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