SG IM FO RUM 2016; 39 (1 ) SHARE HUMANITIES IN MEDICINE John McCrae’s Message to Us Salvatore Mangione, MD

Dr. Mangione is associate professor of medicine and coordinator of medical humanities at Sidney Kimmel Medical College of Thomas Jefferson University.

“If ye break faith with us who die We shall not sleep, though poppies grow In Flanders fields.”

ecember 8, 2015, marked the read not as much as a call to arms— old and soon fell into a dark despair D100th anniversary of the publica - as many first interpreted it, to the from which he never recovered. tion of “In Flanders Fields,” the point of using it for Canadian War As Harvey Cushing noted years most famous poem of World War I. Bonds—but as a plea by the dead to later, “Since those frightful days he Printed anonymously in Punch mag - the living to not let them die in vain. had never been his old gay and com - azine, it told in three stanzas the That thought must have been on the panionable self.” 6 He started taking story of the carnage of war through minds of so many Great War soldiers, long rides on his horse, all alone ex - the voice of its silent victims: the perhaps explaining why this poem be - cept for the company of his dog. Then fallen soldiers. It was a poetic at - came so popular. After all, in Steven in January 1918, just after being pro - tempt to provide meaning to what Spielberg’s Saving Private Ryan , the moted consulting physician to the appeared so utterly meaningless, dying captain Miller makes the same First British Army, Colonel McCrae en - and it immediately resonated. In plea, “Earn this…earn it.” 4 In this re - tered the military hospital of just a few years it transformed the gard, “In Flanders Fields” is not about Wimereux with pneumococcal pneu - poppy—the beautiful image of its those who suffered—it is about those monia. To friends who tried to encour - opening lines—into an enduring who were spared suffering. age him, he replied that he “knew it symbol for both remembrance and McCrae wrote the poem after was the end.” Meningitis developed oblivion. It was, in fact, an ode to seeing his brigade almost wiped out two days later, then coma, and on death by a Canadian poet, physician, by gas at Ypres. Then, ten days later, January 28, 1918, he was dead. and soldier so accustomed to loss a German shell killed a beloved Cana - Cushing, who attended the fu - to be almost in love with the night. dian officer. Alexis Helmer was only neral, wrote in his diary, “Some of John McCrae first experienced 22 at the time, had just graduated the older members of the McGill 1 mortality when only 20 years old. from McGill University, was engaged Unit who still remain were scouring Taking a break from college because to be married, and was literally blown the fields this afternoon to try and of medical problems, he fell in love to pieces. Just before the bombing, find some chance winter poppies to with a young girl of 18 before soon his last words had been, “It has qui - put on his grave—to remind him of losing her to typhoid fever. He was eted a little and I shall try to get a Flanders where he would have pre - never to marry, and death was to be - good sleep.” 3 Afterwards, the only ferred to lie.” 6 come the protagonist of 24 of his 29 intact thing his comrades found was Although McCrae was gone, his published poems. 1 As he wrote to the picture of the sweetheart he was poem lived on. It’s on the Canadian his mother, “Perhaps it is because I to marry. McCrae, also a McGill man, $10 bill and a Canadian stamp, and it was brought into nearer connection had befriended the lad and thus was even earned its author induction into with death that I have ever been be - touched by the absurdity of his the Canadian Medical Hall of Fame. 7 fore, that I think so much about it.” 2 death. He asked to perform his In fact, it still resonates 100 years Outwardly McCrae appeared gre - friend’s burial service and that later because we all hope not to garious, social, and even prone to evening went back to his dressing have lived in vain, we all desire to humor, yet he harbored a sadness station, tending the many wounded make a difference, and we all wish rooted in the awareness of how fleet - and dying. The following morning, to be remembered. ing—at times even meaningless—life May 3, 1915, he was seen walking at Physicians have the privilege of can be. In fact, only two of his poems dawn to a field ambulance near the touching so many lives that it’s no make clear reference to an afterlife, 3 small cemetery where Lieutenant surprise the poem came from a fel - which is odd since he had been raised Helmer had been laid to rest. There, low doctor. McCrae was in fact the in a strong Presbyterian tradition and sitting on the ambulance back steps, kind of doctor who makes us proud his grandfather was a minister. he produced in less than 20 minutes of being physicians, which brings us Hence, “In Flanders Fields” can be his famous poem. 5 He was 42 years continued on page 2 SHARE

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to why “In Flanders Fields” still mat - the British Army—the first Canadian enlargement of the physician’s hori - ters to medicine—especially a medi - to ever receive that honor—is a trib - zon is otherwise important, for scien - cine that wants to be humanistic. ute to his outstanding capacities. tific progress has greatly modified his Before 1910, medical education He was also compassionate and ethical responsibility…. It goes with - was inspired by the Franco-British kind. As a friend later put it, out saying that this type of doctor is model, wherein medicine was a spin- “…through all his life…dogs and chil - first of all an educated man.” 14 off of the humanities and solid hu - dren followed him as shadows follow manistic schooling was considered men. To walk in the streets with him Yet somehow being “cultivated” essential for all students. McCrae’s was a slow procession. Every dog is no longer a tenet of the profession. education was indeed rooted in the and every child one met must be Medical schools have become techni - liberal arts, and as a draftsman, poet, spoken to, and each made answer.” 3 cal schools. The humanistic aspects storyteller, member of the Shake - Lastly, he was an educated man. haven’t been fully shed—we are still speare and Pen & Pencil clubs, singer Hence, the third ingredient of that caring for human beings—but are in the choir, and traveler extraordi - unique mix called “a well-rounded now secondary in both undergradu - naire, he was exactly the kind of mul - healer” was—and still should be— ate and postgraduate curricula. 15,16 tifaceted physician the profession culture. Curiously, culture is not as Hence, John McCrae reminds us once produced in droves: passionately strongly emphasized today as com - of what has been lost (and forgotten) curious of everything human. Then passion and competence, and yet it in the well-justified rush to imple - the 1910 Flexner Report moved the is the one ingredient whose pres - ment Flexner’s recommendations. curriculum to a German model, with ence was considered fundamental He reminds us that being physicians an emphasis on the lab, the white until the Flexner Report of 1910. ought to be something larger than coat, and the supremacy of science. Writing in 1902 about the “four great being mere technicians. If this 2 As a result, doctors like McCrae have features of [our] guild,” 13 Osler premise is accepted, then the next become increasingly rare. Medicine pointed out how medicine had to be step is to recognize those personal now holds the record for the profes - the profession of a “cultivated gen - traits that made people like him pos - sion with the highest suicide rate, 8 a tleman.” And even Flexner included sible so that we can start recruiting close to 50% burnout rate, 9 dwindling in his 346-page report an often-for - for them and then nurturing them empathy, 10 and a disturbing tendency gotten passage where he mentions during training. If this premise is in - for physicians to quit. 11 What went so the “varied and enlarging cultural ex - stead rejected, McCrae may still wrong in 100 years of medical tri - perience” that he considered so im - serve as an inspiring reminder to the umphs? What did we lose along the portant to the education of younger generation of the kind of way? Can McCrae teach us how to physicians: men and women that medicine was best extract meaning from pain, pro - able to produce—and hopefully will tect ourselves in the process, and “…the practitioner deals with facts produce again. After all, without the comfort and relieve others even when of two categories. Chemistry, past there is no future. we cannot fully cure them? If so, physics, biology enable him to appre - what were the traits that made him hend one set; yet, he needs a differ - References such a wonderful healer? ent apperceptive and appreciative 1. Neilson S. John McCrae on The first was undoubtedly com - apparatus to deal with other, more death. Can Med Assoc J 2009; petence. Trained by Osler in Balti - subtle elements. Specific preparation 181(10):717-9. more and later at McGill, McCrae is in this direction much more diffi - 2. Graves D. A crown of life: the was the most “talented” Canadian cult; one must rely for the requisite world of John McCrae. St. doctor of his generation. 12 His ap - insight and sympathy on a varied and Catharines, Ontario: Vanwell pointment as consulting physician to enlarging cultural experience. Such continued on page 3

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Publishing Limited, 1997. 8. Austin AE, van den Heuvel C, address to the Canadian Medical 3. McCrae J. In Flanders Fields and Byard RW. Physician suicide. J Association, Montreal (17 other poems. Toronto: William Forensic Sci 2013; 58 Suppl September 1902). The Montreal Briggs, 1919. 1:S91-3. Medical Journal XXXI. 4. Biguenet J. The profound 9. Shanafelt TD, Boone S, Tan L, et 14. Flexner A. Medical education in contradiction of Saving Private al. Burnout and satisfaction with the United States and Canada: a Ryan. The Atlantic Monthly, June work-life balance among US report to the Carnegie Foundation 5, 2014. physicians relative to the general for the Advancement of Teaching, 5. Swinton WE. Physicians in US population. Arch Intern Med Bulletin No. 4. New York City: literature: part I. John McCrae, 2012; 172:1377-85. The Carnegie Foundation for the physician, soldier, poet. Can Med 10. Weatherall D. The inhumanity of Advancement of Teaching, 1910. Assoc J 1975; 113(9):900-2. medicine. BMJ 1994; 309:1671-2. 15. Thomas L. Notes of a biology- 6. Cushing H. From a surgeon’s 11. Krauthammer C. Why doctors watcher. How to fix the journal 1915-1918. Boston: Little, quit. The Washington Post, May premedical curriculum. N Engl J Brown and Company, 1936. 28, 2015. Med 1978; 298:1180-1. 7. Dr. John McCrae, Canadian 12. Lieutenant-Colonel John McCrae, 16. Gunderman RB, Kanter SL. Medical Hall of Fame. http://cdn BA, MB, MRCP. Can Med Assoc Perspective: “How to fix the medhall.org/inductees/dr- J 1918; 8(3):242-8. premedical curriculum” revisited. john-mccrae 13. Osler W. Chauvinism in medicine: Acad Med 2008; 83:1158-61. SGIM

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