Nearly a century ago, the distinguished philosopher, psychologist, and educator John Dewey opined, “We don’t learn from experience…we learn from reflecting on experience.” Anesthesia and the Classics: Essays on Avatars of Professional Values by Robert S. Holzman, M.D., M.A. (Hon), F.A.A.P., introduces 25 thoughtful and perceptive essays designed to enhance readers’ professional growth through reflection on the daily experience of caring for patients—and interacting with colleagues—in all their human dimensions. Dr. Holzman, a Professor of Anesthesia at Harvard Medical School (Boston, Massachusetts) and Senior Associate in Perioperative Anesthesia at Boston Children’s Hospital (Boston, Massachusetts), creatively and engagingly illustrates the principles, values, traits, and behaviors inherent in professionalism by featuring classical allegories and personae. Further, he connects the values personified by the family of Asklepios (Latin: Aesculapius), the god of medicine, to current medical training and education. The result is a captivating book, remarkable in its depth of familiarity with classical mythology, that highlights the human condition and the obligations of medical professionals in all their complexity and nuance.
“Professionalism” in anesthesiology had an inauspicious beginning with the antics of dentist William T.G. Morton and Charles T. Jackson, M.D., who engaged in petty squabbles and rivalries for purposes of self-enrichment and self-aggrandizement. Although circumstances and context evolve, arguably, ageless conundrums confront every generation of physicians. The requirements for professionalism in medicine, and particularly in anesthesiology, include but are not limited to knowledge, skill, wisdom, empathy, situational awareness, accountability, teamwork, commitment to lifelong learning, and attention to detail. These are not dissimilar to the ideals of empathy, knowledge, generosity, respect, and scholarship that were so highly prized by the family of Asklepios. Moreover, these traits and behaviors are fundamental not only to effective patient care but also to molding one’s professional growth.
A foundation of Western medical professionalism, the original Hippocratic Oath, begins with the words, “I swear by Apollo the physician, and Asklepios, and Hygieia and Panakea and all the gods and goddesses as my witnesses, that, according to my ability and judgment, I will keep this Oath and this contract…”1 Dr. Holzman makes the astute observation that professionals are more than merely experts, and that this distinction was fully appreciated by the ancients. Although Apollo was the first physician, he is not recognized as the father of medicine. It is his son, Asklepios, who holds that honor. Although Apollo had curative powers, he also possessed intentionally harmful powers. In contrast, Asklepios lacked the threatening capability of Apollo and manifested additional positive aspects of his learned profession, including compassion, trust, and altruism.
From the fifth century B.C.E. onwards, Asklepios represents the healing aspects of the medical arts, as do his five daughters, the Asklepiades. They are the personification of health and disease prevention (Hygeia); recovery and recuperation from illness (Iaso); the healing process (Akeso [Latin: Aceso]); healing, cures, and universal remedy (Panakeia [Latin: Panacea]); medications or pharmacy (Meditrina); and good health and natural beauty (Aglaia [Latin: Aglaea]).
In the introduction to his book, Dr. Holzman intriguingly compares anesthesiologists to the two-faced Roman god Janus. While Shakespeare starkly depicted Janus as an icon of deception in Othello (Act I, Scene 2), the classical image of Janus represents the passage of time, the god who looked in two directions, at the past and at the future. Moreover, Holzman suggests, within the context of patient care, Janus represents the accumulation of knowledge, skill, and wisdom acquired with time. As a result, Janus bifrons was able to select interventions to ameliorate the seemingly inevitable. Holzman underscores that while other individuals in the operating room are participating in the contemporaneous surgical dance to the music of the current time, the anesthesiologist is the maestro of the beginning and end, reflecting on the patient’s past medical history, being attentive to current circumstances, and staying a step ahead of the several uncertainties that coincide with the surgical experience. Like Janus, the vigilant anesthesiologist is ready to immediately intervene to prevent catastrophe.
In the Bible, everything was Paradise until Adam and Eve transgressed with the apple. Dr. Holzman reminds us that in Hellenic mythology, everything was sanguine until Pandora’s curiosity caused her to open the jar, allowing disease and suffering to escape, leaving only Hope within the container. This set the stage for medicine to understand disease, and for professionalism to understand the suffering, pain, and hope that are part of the human condition and often accompany disease. Dr. Holzman muses that perhaps hope is an underrepresented topic in contemporary medical education and should be studied more intensively. He alludes to The Anatomy of Hope by Jerome Groopman, M.D.,2 and he acknowledges the important role of hope, especially in pain medicine and critical care.
In addition to discussing the qualities embodied by professionalism, the author expounds on the human condition, emotions, society, fairness, democracy, and other germane topics. Perhaps one of the most absorbing sections of this discerning book focuses on morality, which the author points out is etymologically indistinguishable from ethics. This section is divided into brief chapters on truth and lies, respect, justice, kindliness, and self-control, which are personified as Aletheia (Latin: Veritas) and Pseudologos, Aedos, Dike, Philophrosyne, and Sophrosyne, respectively. (Ironically, lethe. which means “oblivion” or “concealment,” was the basis for the initial name—Letheon—selected by Morton for his “new invention” to conceal its true identity [sulfuric ether]). The essayist provides contemporary (often wry) instances of how these traits or behaviors might be displayed (or not) in the operating room. The illustrative examples are notable in their adroit and accurate reflection of everyday operating room and perioperative reality. A few illustrations follow.
We currently and colloquially speak of “transparency” in the physician\patient relationship. It was Pindar who suggested that Truth was at the root of all virtue, and Dr. Holzman asks whether transparency, honesty, and truth or integrity represent a continuum, or discontinuous points. Although transparency has become a modern-day synonym for honesty and truth, Holzman argues that transparency is a weaker term, indicating only what happened. In contrast, honesty reveals why something happened. In other words, honesty means telling the truth even when one has not been asked a specific question. He provides the following illustration. Transparency puts every state employee’s salary into a searchable database. Honesty involves acknowledging that the highest paid secretary is the boss’s cousin. And integrity is not hiring the boss’s cousin to begin with.
No doubt many of us were taken aback in recent years when political discourse promoted the concept of “alternative facts.” Dr. Holzman discusses theories of truth: the correspondence theory (a judgment is true when it corresponds to the external reality); the coherence theory (contextual basis of truth, conforming to partisan truth); the constructionist theory, which is historically and culturally specific; and the consensus theory (truth is whatever is agreed upon by a specific group). The respected Islamic physician Avicenna (Ibn Sina, 980 to1037 C.E.) unequivocally subscribed to the correspondence theory when he defined truth as “what corresponds in the mind to what is outside it.” One hopes that modern physicians endorse this time-honored definition.
Finally, Dr. Holzman comments on the ironic fact that deception in the operating room can be flagrantly obvious, yet its confrontation is uncomfortably challenging.
Anesthesiologist: How much longer until you are done?
Surgeon: Why?
Anesthesiologist: I’m trying to time the end of the anesthetic.
Surgeon: 10 minutes.
Anesthesiologist (45 minutes later): I thought you said 10
minutes…
“So it goes,” as Kurt Vonnegut would comment. To play devil’s advocate, however, I would argue that the above scenario does not constitute a deliberate attempt by the surgeon to deceive the anesthesiologist. Rather, the behavior is an example of self-deception that does not conform to the correspondence theory of truth.
Spatial constraints do not allow this reviewer to expand on all the history and wisdom included in this erudite yet readable book. In his Postface essay, Dr. Holzman reflects on Titian’s (circa 1488/1490 to 1576) “Allegory of Prudence,” depicting a three-headed figure representing the three ages of man: youth, maturity, and old age. The author notes that an individual’s career has a beginning, middle, and end, and these epochs are not abrupt. Rather, they comprise “a complex choreography and segue from one to the other.” The professional constantly builds on knowledge, skill, and wisdom, and the fluidity of navigating among knowledge, skill, and wisdom is both a trial and a privilege.
Anesthesia and the Classics: Essays on Avatars of Professional Values warrants being chewed, digested, and ruminated upon. It deserves to be the foundation of, and stimulus for, lively and productive discussions of professionalism in anesthesiology programs throughout the nation. Trainees and faculty alike, as well as certified registered nurse anesthetists and anesthesia assistants, will benefit from reflecting on the messages about the enduring values, traits, and behaviors integral to professionalism contained within its pages.
Competing Interests
The author received no funding for this article. During the past 36 months, she has received money from the Accreditation Council for Graduate Medical Education (Chicago, Illinois), Current Reviews in Clinical Anesthesia, and UpToDate. These financial relationships, however, are not relevant to this book review.
