Introduction
In 2012, Dartmouth College renamed its medical school, founded in 1797, the Audrey and Theodor Geisel School of Medicine. Theodor Geisel (1904–91), better known as Dr. Seuss, worked as “an advertisement agency artist, animator, producer and director of animated cartoons . . . playwright, short story writer, documentary filmmaker, lyricist, teacher, political cartoonist, and editor and author of children’s books.”Footnote 1 Most people simply know him as an author of children’s books such as The Cat in the Hat.Footnote 2 Using the renaming of the medical school of Dartmouth College as a foil, I offer in this article a vision of what it might mean to align Dr. Seuss with doctors by examining Geisel’s You’re Only Old Once! A Book for Obsolete Children.Footnote 3 I argue that You’re Only Old Once! can be used as a resource for medical education if it is read as a pathography.
Anne Hawkins has defined pathography as “autobiographies and biographies that describe experiences of illness.”Footnote 4 Published on Geisel’s 82nd birthday, You’re Only Old Once! describes an elderly man’s visit to the Golden Years Clinic, with its interminable waits, paucity of information, and undignified examinations. The book, I suggest, is Geisel’s attempt to restore the patient’s voice to the medical enterprise—the greatest promise that pathography offers, according to Hawkins, as we will see—which he does by humorously fictionalizing his own experience. Indeed, when asked why he chose to write a book for adults, Geisel noted that he had been having some medical problems and found himself waiting in the vestibules of hospitals more often than at his drawing boards; thus his solution was to bring his sketch pad with him to the hospital: “I began to take sketch pads with me and amused myself by thinking of the horrible things they were going to do to me next.”Footnote 5 Moreover, the authorized biography of Geisel contains a chapter on You’re Only Old Once!; in it, the biographers, Judith Morgan and Neil Morgan, note that “the book was his unexpected lamentation about the infirmities of age and the indignities of the health-care system, written when he was ‘fed up with a social life consisting entirely of doctors.’”Footnote 6
Description of You’re Only Old Once!
You’re Only Old Once! begins with an unnamed old man sitting in the waiting room of the Golden Years Clinic, reading an article about a faraway land called Fotta-fa-Zee. In this land everyone feels fine in old age because the air is clean and people eat organically. This is a place where there is no need for doctors. But the man who is reading the article has come to the Golden Years Clinic because he is not feeling very well.
In the book, the old man takes a number of tests. He visits with various “Quiz-Docs,” and they bombard him with questions, asking “point blank” about every part of his body as well as those belonging to his extended family. The old man is depicted half-naked in an “Ogler” machine, having his stomach and chest examined. As the Oglers “silently” and “grimly” observe the man, the Ogler machine reads that the old man’s health is bad. After these tests, the old man finds himself back in the waiting room. Despite the fact that he has seen many doctors, none have spoken a word to him about their findings. The only sympathy he receives is from Norval, the fish in the fish tank of the waiting room. He waits for several hours, becoming increasingly anxious about the results of his many tests. This cycle—receiving tests, awaiting results, receiving more tests—is repeated several times throughout the narrative.
Toward the end of the book, the old man goes to a room to receive his pills and instructions on when to take them. Geisel offers several pages of rhyme in which the old man is given orders that require him to take pills at breakfast, after lunch, before every meal, between every meal, and every other night at bedtime. Additionally, there are pills for specific situations. After receiving all of his pills, the next step is to ensure that the old man—and his heirs!—may be billed properly. Here Geisel depicts the old man sitting in front of a conveyer belt that is bringing him what seems to be an endless number of forms to fill out. After filling out all of this paperwork, the old man is finally permitted to put his clothes back on—he has been depicted throughout most of the book in a hospital gown—but even here coats, socks, and pants have their own specialized rooms for retrieval. The book ends on a positive note, as the old man feels pretty good—for the shape he is in.
You’re Only Old Once! as an Educational Resource
My argument, as noted, is that You’re Only Old Once!, if read as a pathography, can be used as a resource in medical education. In Reconstructing Illness: Studies in Pathography, Hawkins writes:
It is in restoring the patient’s voice to the medical enterprise that the study of pathography has its greatest importance and offers its greatest promise. . . . It is surely no accident that the appearance of pathography coincides with the triumph of scientific technological medicine. The price we are paying for its remarkable achievements is felt by the individuals whose bodies can be so miraculously repaired, and it is a human price. We recognize this cost when patients fear their treatment more than their disease, when a hospital experience is compared to incarceration.Footnote 7
You’re Only Old Once! quickly sold out on its first printing of 200,000 copies and rose to the top of the New York Times best-seller list for nonfiction,Footnote 8 which seems to indicate that the readers of the book knew, either intuitively or from their own experience, that what Geisel is describing is an accurate portrayal. In any case, if, as Hawkins suggests, the essence of pathography is in restoring the patient’s voice to the medical enterprise, then what is it that Geisel would want doctors and those who train doctors to hear? What might he have said to medical students and medical educators on the occasion of the renaming of the Audrey and Theodor Geisel School of Medicine? There is no better place to look than You’re Only Old Once! In what follows, I offer four critiques of modern medicine derived from You’re Only Old Once! as well as four strategies for using it as a device in medical education.
Four Critiques of Modern Medicine
One critique derived from You’re Only Old Once! is that progress has a price. Although living in the United States offers perhaps the best medicine has to offer in terms of technology, there are, at the same time, certain health-related drawbacks. Unlike the idyllic Fotta-fa-Zee, some areas of the United States—the apparent setting of the book—are polluted due to industrial development. Also, most Americans do not live off the land, eating from Tutt-a-Tutt trees, and a number of them suffer from a poorer quality of health because of a diet of mass-produced food.
A second critique is that the logistics of healthcare need reworking. A common complaint is that much of going to the hospital involves waiting in lobbies. Can this seemingly endless waiting time be eliminated? If not, can something be done to address the problem by making this time more pleasant? Geisel quite literally took matters into his own hands as he took his sketch pad with him to draw the old man waiting in the lobby of the Golden Years Clinic. Maybe there is a lesson here for all of us. Perhaps this is an issue to be solved not systematically but rather personally. Another logistical problem involves the fact that, in clinics and in hospitals, patients are often unaware of the costs of the tests they are undergoing. Is there a way for hospitals to be more transparent about costs? Additionally, even the process of taking off one’s clothes to be examined is inherently indignifying. In the book, the old man is ogled by many Oglers. How, if at all, might those who administer these tests and other aspects of medicine treat the patient with more respect? Hospitals are depicted as confusing and unwelcoming places. What can hospital ergonomics do to take more human factors into account?Footnote 9
A third critique involves communication skills. There is sometimes a lack of simple politeness—replaced with unnecessary bluntness—in the way healthcare professionals interact with patients, as, for example, when taking patient histories. Many commentators have noted that old-fashioned bedside manner seems to have suffered in recent decades (the rise in pathographies is a response to this trend in medicine).Footnote 10 Should the future of medicine, at least to some degree, be found in the past? Also, with regard to the taking of patient histories, from the patient’s point of view, the questions that healthcare professionals ask do not always seem relevant. For example, the old man is asked if his cousins suffered from wild nightmares. Is there a way for doctors to be less obtuse regarding why they are asking the questions that they ask? Geisel also observes that, during examinations, healthcare professionals often do not directly communicate their findings but rather communicate their intuitions indirectly—and disturbingly—with silent grimaces.
A fourth critique is that medicine, as it is practiced today in the United States, is overspecialized, overly technological, overly pharmacological, and overly bureaucratic—the drawings in the book display this vividly. Would we be better off with fewer specialists and more generalists? Can medicine be practiced more simply? Geisel seems to hope so. In any case, the four critiques offered by Geisel are not new. Indeed, one can find many resources on these issues in various fields in and related to bioethics, including medical humanities, public health, and health policy. Rather than new critiques, what You’re Only Old Once! offers medical education is a new, and perhaps nonthreatening, way into much-needed discussions.
Admittedly, the time devoted to ethics and professionalism and related nonbiomedical aspects of medical education is necessarily limited, and there are debates as to whether such topics should be incorporated into the required curriculum or offered as elective courses.Footnote 11 In what follows, I suggest four places in which You’re Only Old Once! could be used, weighing the pros and cons of each placement and keeping in mind the time constraints of medical education. My suggestions are based on my teaching experience at the University of Texas Medical School in Houston, Texas.
Four Strategies for Medical Education
The first place in which I suggest that You’re Only Old Once! could be incorporated is during the opening lecture of the first class of medical school, such as Introduction to Clinical Medicine. Currently, a similar exercise is being used at the University of Texas Medical School at Houston. The course director displays a picture of Sesame Street’s Elmo—a fuzzy character with red fur—and medical students attempt to offer a diagnostic assessment of Elmo. The exercise works because it breaks the ice by using humor to mitigate the excitement and the anxiety of the first day of medical school. You’re Only Old Once! could be employed in a similar way, not to prompt students to begin offering diagnoses but rather to invite students to think about medicine from the patient’s point of view. The strength of this approach is that it would encourage students to think about ethics and professionalism early—from day one—but a weakness lies in the fact that not much time would be devoted to discussing the issues raised by the book (the Elmo exercise, for example, takes less than five minutes). Also, the discussion would likely be informed primarily by, or only by, opinion.
The second place in which I suggest that You’re Only Old Once! could be used is as a case in a required ethics and professionalism course, usually offered during the basic science years of medical education. Such courses are now common in medical schools.Footnote 12 At the University of Texas Medical School at Houston, we currently offer such a course, which consists of team-based learning sessions and small group sessions. In the small group sessions, which last for 90 minutes, two cases are discussed (45 minutes per case). Also, additional textbook readings and journal articles are required prior to class, with the benefit that the discussion of the cases is informed by scholarly resources. The strength of using You’re Only Old Once! in such a course is that substantial time could be devoted to discussing the various issues generated by the book and that the session would be enriched by substantive data and informed inquiry. But a weakness is that students would have limited clinical experience, and therefore a less in-depth understanding of You’re Only Old Once!
The third place in which I suggest that You’re Only Old Once! could be used is as a case during the clinical years of medical education. At the University of Texas Medical School at Houston, the McGovern Center for Humanities and Ethics offers one hour of instruction in each of the core clerkships during the third year. These sessions consist of various approaches to teaching humanities and ethics. For example, I use podcasts from the radio broadcast This American Life in both the family medicine clerkship and the psychiatry clerkship to discuss ethical issues relating to disability claims (the topic for family medicine) and to stigma (the topic for psychiatry). In other clerkships, students read and discuss short ethics cases. You’re Only Old Once! could be used as a case discussion in, for example, geriatrics or family medicine. The strength of this method is that more time could be devoted to discussing the book (discussion of cases usually takes 15 minutes), and the discussion would be informed by the students’ current training experiences.
The fourth place in which I suggest that You’re Only Old Once! could be used is in seminar discussions during the fourth year of medical education. It is common for medical schools in the United States to offer electives during the fourth year. At the University of Texas Medical School at Houston, I direct two such courses: Humanistic Elements of Medicine and Pathographies of Mental Illness. Such courses, because they are offered at the culmination of medical education, are deeply informed by the medical students’ personal clinical experiences. There are beneficial results in that, as a nonphysician, I learn from the students, and they have much to offer one another in their shared reflections on their many hours spent in the clinic. My courses are also reading intensive. In my Pathographies of Mental Illness course, for example, I assign twelve books, and the course is run as a humanities-style graduate seminar, meaning that the course meets three times a week, and each session meets for three hours (a book is discussed during each session). With regard to You’re Only Old Once!, a course, or part of a course, could be designed around the book in which, after students have read and discussed the book, monographs in bioethics, medical humanities, public health, and health policy are assigned in follow-up sessions. (For example, on the effects of pollution and the social determinants of health, students could explore the World Health Organization’s websiteFootnote 13 and could discuss the question, “To what extent is it the role of physicians to address issues such as pollution—is this within the role of the doctor?” Students could also engage You’re Only Old Once! by discussing the drawbacks of modern technological medicine in light of Daniel Callahan’s Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System.Footnote 14 Or students could debate the extent to which they think persons in the United States are overmedicated, in light of data reported on Howard Brody’s blog.Footnote 15 These are just three suggestions—there are many more possibilities medical educators could pursue.) The strength of this approach is that it would explore the issues raised by You’re Only Old Once! deeply and rigorously, but the weakness is that the book would be introduced at the end, rather than the beginning, of medical education, perhaps limiting its ability to affect the professional identity formation of students.Footnote 16
Conclusion
When Geisel was once asked if he thought that he was subversive, he replied: “I’m subversive as hell!” He added: “I’ve always had a mistrust of adults.”Footnote 17You’re Only Old Once! depicts, with Geisel’s usual humor, his mistrust of doctors and the healthcare system. Thus, in offering an answer as to what it might mean to align Dr. Seuss with doctors (a question inspired by the renaming of Dartmouth College’s medical school), one must deal with You’re Only Old Once! The irony is that the book does not portray doctors, or medicine, in a good light. But Geisel is not simply subversive and critical; he is also constructive and hopeful. In many of his children’s books, he ends with a question—asking children what they would do if they were in this situation.Footnote 18 The effect of this strategy is that Geisel is able to be morally minded without being moralistic; he provokes inquiry without being didactic. And this pedagogical stance, I suggest, is especially helpful for medical ethics education because medical education in general tends to be heavily didactic, leaving little room for creativity and inquiry.Footnote 19 In this article, I have derived four critiques of modern medicine from You’re Only Old Once!, and I have offered four places in which these critiques could be explored in medical education, weighing the pros and cons of each placement. However You’re Only Old Once! may be used in medical education, it seems to me that Geisel would want medical students to be subversive as hell for the sake of their patients, restoring individual voices in face of unfeeling institutions.
“I can’t go back to doctors,” Geisel stated, “after what I did to them in [You’re Only Old Once!],”Footnote 20 one review of the book notes. I think most of us disagree with Geisel on this point; Dartmouth certainly does. And I think that most of us would agree that individuals and institutions would do well to welcome Geisel—and his subversive spirit—with open arms.
