Photos and thoughts from a life in medicine by Sheldon Gottlieb, MD Dr. Shel Gottlieb is a practicing Cardiologist at the Johns Hopkins Bayview Medical Center, formerly City Hospital, where he has provided cardiac intensive care to critically ill patients and outpatient care for congestive heart failure patients since 1973. His ability to listen intently and his deep and caring connections to his patients and their families at times of health crises are an inspiration to the many medical students, residents, and fellows that he has helped train. This gallery of photos was taken by Dr. Gottlieb over decades of service to illustrate the caring embodied in medicine. It is presented here with Dr. Gottlieb’s thoughts and a selection of quotes on the topic chosen by him. The genesis of the project: In the spring of 2010 I was given the honor of spending an hour with a visiting Professor, one of the most caring physicians whom I will ever meet, Dr. Richard Panush. I didn’t know what to talk about so I brought photos I had taken during my internship year almost 30 years earlier. As I stood in the hallway afterwards clutching my portfolio, Dr. Hellmann turned to me and asked me to “take pictures of caring” in the hospital. We did not discuss exactly what he meant by “caring,” how the photographs were to be taken, their content, or how photographs could illustrate the fact of or process of caring. We did not discuss any terms or conditions. I simply said ‘yes.’--Dr. Shel Gottlieb Seeing with a new lens: I began carrying a camera and photo release forms with me on rounds. Looking with the eyes of a photographer, wanting to capture caring, I began more closely observing the house staff as they interacted with patients. I began to see decisive moments, pictures or tableaux of caring. And also moments of not caring. Some house staff would look for a chair to sit down on when they talked to the patient, others would stand, with their gaze on the monitor screen or the other doctors, not the patient. Looking at these interactions from behind a camera changed how I taught medicine. I began to carry a tripod stool along with the camera, and to “suggest” to the house staff that they sit to talk to the patient.--Dr. Shel Gottlieb Being a physician is more than medical: Abraham Fuks, James Brawer, and J. Donald Boudreau call the best performance of medicine “Physicianship.” (Fuks A, Brawer J, Boudreau JD 2012 Perspectives in Biol and Med 1(55):114-126). These authors suggest the virtue of medicine includes excellence in knowledge and performance combined with compassion - answering patients’ need to have a physician who answers the call of duty and says “here I am.” Physicianship has both analytical and intuitive components. The quality of reaching out to the patient, of feeling their distress, has been called empathy. As an expression of caring, the essence of empathy remains mysterious. Yet physicianship it is more than empathy, or even embodiment of the cardinal virtues proposed in the Belmont Report of Autonomy, Beneficence, Non-Malfeasance, and Justice. Caring, according to virtue theory is that “something deep within an agent [which] comes to expression in moral action” (van Hooft S, Bioethics and caring, 1996 J Medical Ethics 22: 83-89). These photographs strive to illustrate “Caring” as an exhibit of moral education in the dimensions of Caring.--Dr. Shel Gottlieb Caring is not separate from doctoring: The iconic moment of caring is when the house staff physician sits down at the patient’s right side, holds the patient’s wrist to palpate the radial pulse, and talks to the patient, using common words while looking at the patient’s face. This is the traditional expression of the relationship between physician and patient, as seen in many pictures of Osler at the bedside, portraits of “The Doctor” by Luke Fields [Tate Museum, London], and in Picasso’s earliest publicly displayed picture, “Science and Art” [Picasso Museum, Barcelona] where Picasso’s father was the model for the physician sitting at the patient’s right arm.--Dr. Shel Gottlieb “The physician’s task is not to meet the minimum standards stipulated by a contract but rather to be worthy of trust, not to behave in a certain manner because one is constrained to do so but rather because one feels a genuine commitment to the values of an oath.” -- Swick HM, Bryan CS, Longo LDBeyond the physician charter: reflections on medical professionalism, Perspectives in Biology and Medicine, 2006; 49 (2): 263-275 “The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”-- Francis Peabody M.D.,The care of the patient, JAMA 1927;88:877-882 “Photography is a tool for dealing with things everybody knows about but isn’t attending to. My photographs are intended to represent something you don’t see.”-- Emmet Gowin, quoted by Sontag, On Photography, p. 200 “The average practitioner is used to seeing his patients flash by him like shooting stars — out of darkness into darkness. He has been trained to focus upon a single suspected organ till he thinks of his patients almost like disembodied diseases.” -- Richard C Cabot., M.D., “Social Service and the art of healing,” New York, Moffat, Yard and Company, 1909, p. 33. “All photographs are memento mori. To take a photograph is to participate in another person’s (or thing’s) mortality, vulnerability, mutability. Precisely by slicing out this moment and freezing it, all photographs testify to time’s relentless melt.”-- Susan Sontag, On Photography, New York, Farrar, Straus and Giroux, 1978, p.15
![Abraham Fuks, James Brawer, and J. Donald Boudreau call the best performance of medicine “Physicianship.” (Fuks A, Brawer J, Boudreau JD 2012 Perspectives in Biol and Med 1(55):114-126). These authors suggest the virtue of medicine includes excellence in knowledge and performance combined with compassion - answering patients’ need to have a physician who answers the call of duty and says “here I am.” Physicianship has both analytical and intuitive components. The quality of reaching out to the patient, of feeling their distress, has been called empathy. As an expression of caring, the essence of empathy remains mysterious. Yet physicianship it is more than empathy, or even embodiment of the cardinal virtues proposed in the Belmont Report of Autonomy, Beneficence, Non-Malfeasance, and Justice. Caring, according to virtue theory is that “something deep within an agent [which] comes to expression in moral action” (van Hooft S, Bioethics and caring, 1996 J Medical Ethics 22: 83-89). These photographs strive to illustrate “Caring” as an exhibit of moral education in the dimensions of Caring.--Dr. Shel Gottlieb](images/clinic_patients_listening_110422.jpg "Being a physician is more than medical:")
![The iconic moment of caring is when the house staff physician sits down at the patient’s right side, holds the patient’s wrist to palpate the radial pulse, and talks to the patient, using common words while looking at the patient’s face. This is the traditional expression of the relationship between physician and patient, as seen in many pictures of Osler at the bedside, portraits of “The Doctor” by Luke Fields [Tate Museum, London], and in Picasso’s earliest publicly displayed picture, “Science and Art” [Picasso Museum, Barcelona] where Picasso’s father was the model for the physician sitting at the patient’s right arm.--Dr. Shel Gottlieb](images/Geriatric Archie Smothers (1).jpg "Caring is not separate from doctoring:")
