In this episode of The Future of Medicine, host Dr. Euan Ashley is joined by Dr. Arthur Kleinman — psychiatrist, medical anthropologist, and one of the most influential thinkers on illness, caregiving, and the human experience of medicine. Across a wide-ranging and deeply reflective conversation, Dr. Kleinman explores the enduring distinction between curing disease and caring for people, arguing that medicine cannot succeed without truly understanding patients’ lived experiences.
Drawing on decades of clinical practice, teaching, and scholarship — including his landmark works The Illness Narratives and The Soul of Care — Dr. Kleinman reflects on why communication remains one of medicine’s most under-taught yet essential skills. He discusses how medical training can unintentionally erode clinicians’ ability to listen, the moral importance of narrative and presence, and why patients so often value feeling heard as much as — or more than — technical expertise.
The conversation also looks ahead, examining the role of AI in healthcare. While Dr. Kleinman sees enormous promise in technology as a tool to support clinicians and reduce administrative burden, he makes a compelling case that wisdom, empathy, and human connection can never be automated.
From medical education and burnout to caregiving at the end of life, this episode offers a powerful reminder of why humanity must remain at the center of medicine — even as innovation accelerates.
The Intro
“AI can do certain things. It cannot participate in the quest for wisdom.”
Dr. Arthur Kleinman is a psychiatrist and medical anthropologist whose work has reshaped how we understand illness and caregiving. For over four decades at Harvard, he has led efforts to bridge medicine and human experience.
“If you didn’t know the illness experience, you couldn’t take care of the disease. Okay.”
Authoring landmark books such as The Illness Narratives and The Soul of Care that explore what it means to suffer, heal, and care deeply.
“Communication is critical to medicine, but most American medical schools do not train in learning how to communicate to patients.”
Today’s conversation promises a rare insight into the human side of medicine — how we care, how we suffer, and why those stories matter.
Welcome to Stanford Department of Medicine’s inside look at the future of medicine.
The Transcript
Dr. Euan Ashley: Arthur, welcome back to Stanford. You trained here. Tell me a little bit about how Stanford shaped your career. You’ve obviously spent most of your time—
Dr. Arthur Kleinman: Oh, absolutely. I was an undergraduate here and went to medical school here, and it was a different medical school. And, uh, I was quite connected to the Department of Medicine because Hal Holman, who then was the chair of medicine, was a real good friend. And, um, uh — but it was a different medical school that was dominated by basic scientists.
Dr. Ashley: Yeah.
Dr. Kleinman: And clinicians had — all the great clinicians had been left in San Francisco when the medical school moved down here. Right. And so you had just young clinicians who sort of didn’t have the power to influence the education. Hence, we were educated more toward science than we were toward care. Um, and my subject is care today. So that’s interesting. But I’ll tell you that when I left Stanford and was an intern in internal medicine at the Yale–New Haven Hospital, the first day that I was an intern, uh, the other intern handed off to me 17 patients, uh, half of whom had MIs and, uh, pulmonary emboli. And I hadn’t seen a single MI or pulmonary embolus here at Stanford. Okay. And so I wrote back to, uh, Dean Alway and told him, you know, you trained me scientifically. Yeah. But you did a lousy job of preparing me clinically for the rest of my life. I was hoping that that would increase that. Yeah. But now I can see that it’s a different place. You’ve got the facilities, which we really didn’t have at that stage, and you’ve got the patient mix, etc.
Dr. Ashley: Well, just a moment ago, we were talking about my homeland, Scotland. And, um, one of the things I remember from my early training was seeing essentially multiple MIs every single day. I came from Glasgow in the west of Scotland, where the heart attack rate is as high as anywhere in the world — it was at the time. I moved from there to Oxford, where it was a little lower, and then moved from there to Stanford, where it was much lower again. So in some ways we’ve had a parallel, yeah, early path there.
Dr. Kleinman: I mean, I did my OB-GYN — I went to do my OB-GYN in Edinburgh at the, uh, I think it was called the Infirmary or something.
Dr. Ashley: Yeah, the Royal Infirmary. Yeah.
Dr. Kleinman: And, but then since the midwives would not let us near delivering, I left after a week and came back and did it here at Stanford.
Dr. Ashley: Yeah. My mom was a midwife, actually. So I sort of grew up in a family with where she ruled the roost on all things to do with babies. So, um, well that’s amazing. And you’ve had this incredible career, obviously based as a professor at Harvard. Medical anthropology is a field you almost essentially created. And when we read about you online, various words are recurrent — medical anthropology, of course, psychiatry, ethics, but also medical education. Yeah. But maybe start with that first one, medical anthropology, because not everyone is familiar with what that really is.
Dr. Kleinman: Well, you know, it’s interesting that probably at Stanford here, the hospital — if you asked, uh, attendings or residents — they’d have trouble with medical anthropology. If you came to the Mass General or the Brigham, the hospitals at Harvard — yeah — or even the BIDMC system, you’d find that people would give you a definition of medical anthropology because we’ve had generations of terrific medical anthropologists, right? My former students include Paul Farmer.
Dr. Ashley: Yeah.
Dr. Kleinman: Who probably was the icon of global health in the world. Absolutely. Jim Kim, who is the president of the World Bank. Okay. Anne Becker, who is the dean of clinical and academic affairs at Harvard Medical School now, and many, many others — including maybe a quarter of the anthropology department here at Stanford.
Dr. Ashley: Yes. Yes.
Dr. Kleinman: And so medical anthropology is simply — the kind of medical anthropology I’ve tried to do is applying anthropological ideas and methods to clinical care.
Dr. Ashley: Yeah.
Dr. Kleinman: And so the first thing is to recognize that there’s really a close connection between clinical work and ethnography, the method of anthropology, which is just about, in a sense — in a crude sense — learning about the context of people. Yeah. Okay. And you hope — it doesn’t happen all the time — but you hope that doctors are learning about the context of their patients in order to give better care. Okay.
Dr. Ashley: Well, that’s what struck me in reading about your work, in particular, just in preparation for meeting you today, was that we often focus on curing. We’re so focused on curing — and actually we ran away from that word for many years — but maybe now we can actually approach it for some conditions. But I think what you’ve written about so potently is that it’s not really just about curing. It’s about caring and understanding the person behind it.
Dr. Kleinman: Yeah. You know, it’s not an original idea with me or with you. This has been going on for over 150 years. If you think of, uh, William Osler — who left Hopkins to become the Regius Professor at Oxford — his whole argument was about the importance of care for cure. His point was: if you didn’t know the illness experience, you couldn’t take care of the disease. And that’s more or less what I’ve tried to show you can illustrate through anthropology better than many other ways. And then what methods do you have available? And the key method I believe is intensive interviewing — knowing how to interview. Yeah. Knowing how to be. And as a doctor you’re in a privileged place for interviewing because there’s a critical issue. Something is really at stake. People are focused. You’re focused. As long as you keep your attention on the person, yeah, you can quickly get information that you could never get in any other setting. And yet something happens that, as a medical educator for 55 years, I feel is an enormous failure. Now I’ll leave Stanford out of this because I’m sure Stanford does better than everywhere else, but I can put Harvard on this, and Yale, and just about every other university in the United States and its medical school. We have eight major studies that show that graduating medical students are worse than incoming medical students at all the things related to the medical interview, the medical history. Wow. And those emotional and moral aspects that relate to being committed to doing care. Yeah. So for a medical educator, that has got to be a problem. And for chair of Department of Medicine, I think you’re in the perfect place to do something about this because my own diagnosis of this is that what happens that makes medical school wonderful for science and technology, toxic for care, is that — and again I’m excluding Stanford, sure — is that we allow residents to teach medical students. Yeah. So you and I were — you were a registrar, I was a resident. Right. Right. You’re a resident, you’re a survivor. Yeah. I wouldn’t — if I had my ideals, and I tried to get these at Harvard Medical School, but no one has given me the space for them — I wouldn’t allow a resident within 200 yards of a medical student. Simply because you were a resident, I was a resident. Being a resident is survival.
Dr. Ashley: Yeah, that is true.
Dr. Kleinman: You’re in your mid-20s. You want to get out in the world. You want to have a life. You can’t be stuck in the hospital all the time. Okay? So you shortcut things that you shouldn’t shortcut. Okay? And instead of seeing the occasion to really teach the best practices, you actually end up not so much teaching the worst practices, but showing the worst practices — demonstrating them. Yeah. And there’s nothing like demonstrating for a medical student to realize, hey, there really is a hidden curriculum here. Yeah, you know. Yeah. And so, you know, at Harvard, we used — when we were more divided, the last two years clinical, the first two years pre-clinical — we used to call the last two years the cynical years. I see. Yeah. The first two years the pre-cynical, right? Preclinical. Yeah.
Dr. Ashley: Yeah. But I think that certainly one of the things you’re speaking to is the idea that residents are involved in something very practical, right? And so they’re learning shortcuts and they’re learning how to get through the day. And that’s probably not the time of your life when you’re most focused on how you might educate the next generation.
Dr. Kleinman: No. And you know, as a chair at a great medical school, your hands are a little bit tied, I think, to pick service chiefs who really are important because they’re going to demonstrate the quality of care — yeah — for whom care is a central issue. Because in their careers, like in my career and your career, we had to build strong academic careers.
Dr. Ashley: Yeah.
Dr. Kleinman: Not all of us kept care as a central focus. Okay. And yet my feeling is: if you’re a service chief on a clinical service, you must be an outstanding caregiver. And if you’re not, yeah, everything is going to change. That service is not going to value care. Students are going to understand that. Residents will understand that.
Dr. Ashley: No, I completely agree. And it makes complete sense. And I think that your statistic about the data demonstrating that through medical education we make people less good at listening, less good at eliciting narrative — you know, that’s a strong indictment of the way we currently work. You’re kind enough to exclude us, but in reality, we’re no different from anywhere else. And as a community, I think we clearly need to think about that. You’ve written a lot about narrative, in particular.
Dr. Kleinman: Yeah.
Dr. Ashley: And obviously, among your very famous books, maybe the one that most medical students have been most exposed to is The Illness Narratives. Yeah. But talk about that. I’m someone who loves story, and I understand the power of story, but it’s everywhere around. And I think no one has written about it more eloquently or importantly than you have.
Dr. Kleinman: Yeah. Thank you for saying that. Well, at least it was early. I mean, there’s a lot of attention now to narratives, but that was back in the late ’80s. Yeah. Well, I’ll tell you — a misadventure with The Illness Narratives. Because The Illness Narratives, at one stage in the late ’90s, was taught at about half of American medical schools. Yeah. So it was widely used, and I would go to the medical schools, and they would take me on rounds because I’m a clinician and we go on rounds, we see patients. And they say, “Oh, this is a great patient for you, Dr. Kleinman.” Yeah. “This is Mrs. Smith. Here are her electrolytes, her — um — all the hematological workup. Um, this is her X-rays, and this is her illness narrative in one paragraph.” Okay. And it was fixed. You see, it was her illness narrative in one paragraph. It materialized as a substance. Okay. Yeah. Okay. But my whole purpose was — I don’t care what the narrative is. It’s meant to be a conversation opener. But the way it got used was a conversation stopper. Okay. We’ve got this. We show it. That’s it.
Dr. Ashley: This is end of story.
Dr. Kleinman: Exactly. So my interest was really not in narratives. It was in the illness experience. I think focusing on the illness experience — understanding it — that is: what is the person actually experiencing from this disease?
Dr. Ashley: Yeah.
Dr. Kleinman: So, you know, I made this distinction. It came out of the work of a great Yale clinical epidemiologist, Alvin Feinstein, who made a distinction between illness as the experience of the patient, disease as the pathology understood by the doctor.
Dr. Ashley: Right. Right.
Dr. Kleinman: And my concern was that the doctor had to understand both. Yeah. You couldn’t just say, “Okay, I’m listening to the patient. She’s telling me the diagnosis.” Okay. Yeah, you may pick up the diagnosis, but she’s telling you about her life. Okay. And about her experience of being sick and of being treated. And if you take that into account, you’re going to do a hell of a lot better job for her. And the people who do that job, patients really value. And the people who don’t, they don’t value. Yeah. I gave you an example last night in a lecture I gave of studies. We have a number of them now. These are medical anthropological studies comparing orthopedists and chiropractors for low back pain. Yeah. Okay. There’s no question in these studies that the orthopedists have the better outcome. Okay. But if you look at patient satisfaction, it’s astonishing. There’s a paradox that patient satisfaction is with the chiropractors. And when they’re asked, “How could you possibly find the chiropractor better than the orthopedist?” they say, “Well, it was a real person. Yeah. They explain things to me.”
Dr. Ashley: They love their chiropractors.
Dr. Kleinman: Yeah. So, and what is that about? It’s about listening. Someone listened to me. They heard what I was concerned about, and they gave me an explanation that was important. And that’s one of the most interesting things about medicine. Communication, as I’m going to argue in grand rounds, is critical to medicine. Yeah. And yet we don’t train — and again, I’ll exclude Stanford, you may do it — but most American medical schools do not train in learning how to communicate to patients. Meaning just simply metaphors. So if you’re doing hematology, what metaphors do you use when you have leukemia and you want to speak to a patient? Or if you’re dealing with low back pain. Yeah. Or you’re dealing with asthma. What are the metaphors that people will understand? Years ago, I was at the University of Washington for six years, from ’76 to ’82. I had a friend who was a great medical geneticist. His name was Arnold Moser. And Arnold asked me to evaluate his genetic counselors. And so I sat in on 10 sessions by genetic counselors with families — husbands and wives — who had just either delivered a child that couldn’t survive much after delivery or had been dead at the time of delivery. And they were learning about the genetics relevant to the unusual genetic problems that their dead child had had, because they wanted to plan for children in the future. And I had a medical degree, and I sat through these sessions, and I couldn’t understand half of what was being explained. Yeah. So I interviewed the families to find out what they knew. They knew nothing. Yeah. And when I spoke to the counselors, the counselor says, “Well, you know, they must have understood it, because no one asked any questions.” Yeah. And I said, “Well, yeah. They didn’t ask any questions because they were intimidated by you.” Okay. So I think that it’s in reacting that we see doctor skills in being caregivers.
Dr. Ashley: Yeah.
Dr. Kleinman: You explain to a patient what’s happened, and then they think about it. You say, “Come on, you must have a question.” Yeah. They ask the question, and then you respond. And in that response, you really do the job. Yeah — you make it clear what’s at stake, what’s going to happen, how you’re going to proceed, etc. What the issues are, what could be an unintended consequence. All that comes out if it’s a conversation you have.
Dr. Ashley: If it’s a conversation.
Dr. Kleinman: Yeah.
Dr. Ashley: I sometimes actually ask my patients if they would explain back to me what they heard. Terrific. And on one sense, I’m putting them on the spot, so you have to be a little careful with that. On the other hand, it’s really illuminating when you realize what it is they took from what you said.
Dr. Kleinman: Yeah. Two years ago, a colleague of mine at Harvard, who was a great humanist, developed myeloblastic leukemia and asked me to find the best person to do his treatment. Yeah. And I asked around, I got different names. I picked the Harvard colleague who had the best outcomes, and I arranged for them to meet. And two hours after the meeting, this humanist — who was a great guy — called me and said, “Uh, you have to get me a new leukemia expert.” And I said, “No. I got you the best.” “The best.” And he said, “I can’t see him again.” And I said, “You can’t see him again? Why?” He said, “He was so cold and uninterested in me as a person. He simply laid out the odds ratios. And I felt that he could have been giving a lecture to a hundred people rather than speaking with me. I’m not going back to see him.”
Dr. Ashley: Yeah.
Dr. Kleinman: So I mean, you know, it’s — and then you say to yourself, gee, someone who is outstanding in treating the disease, why can’t they also be skilled — at least skilled — in understanding the person? A great author years ago, writing about his medical care, said, “I didn’t want someone who was extraordinary. I simply wanted the decency of the postman.”
Dr. Ashley: Yeah.
Dr. Kleinman: Okay.
Dr. Ashley: Yeah.
Dr. Kleinman: And I thought that was telling.
Dr. Ashley: That’s a really interesting phrase. And I think that, you know, sometimes we’re losing that with our focus on the disease, our focus on the numbers, the odds ratios. We can lose that — the personal connection that would otherwise naturally come first. Yeah. And somehow it gets lost. And even the way we teach how to take a history divides these components. Yeah. As much as a social history is taught is still pretty minimal. It’s not really understanding the person. It’s still separated from the disease history. And I think that, again, your writings have really spoken nicely to the fact those two can’t be separated.
Dr. Kleinman: I’m hopeful for a couple of reasons. One, every medical school I know right now is undergoing curriculum reform in response to these eight studies, amongst many other things, and trying to improve things. So that makes me optimistic. Secondly, I was just with a group — and I’ve been with a number of groups like this. I was with a group of surgeons and anesthesiologists in Montreal, all of whom were concerned about the loss of the human in care.
Dr. Ashley: Yeah.
Dr. Kleinman: And they contribute this in part to the structure of surgery today. So much surgery is day surgery that by the time the surgeon has entered the room, the patient is knocked out. Okay. And by the time the patient recovers enough to speak, it’s the resident who speaks to her, not the surgeon.
Dr. Ashley: Yeah.
Dr. Kleinman: And so they wanted to know: how would you reconfigure things, in the given limits of our practice, to make things more human? Which I say: you know, schedule an appointment in advance where you speak to the person — what’s going to happen, lay it out — and then see them afterward as well. That could be a — you know — and people said, well, you know, we can actually fit that into the kind of system. So part of it is the system. Because I believe that even though the finding is that fourth-year students just sort of lose some of the interest and some of the skills, it isn’t that we’ve deskilled them forever or changed their interest. They’re going to come back to this after their residency, yeah, okay, later in their practice. And what happens is, especially in primary care, is that we see alienation. This is classical Marxist alienation. All right. If you go back and read Capital — mhm — okay. I’m not a Marxist, but I read Capital.
Dr. Ashley: Okay. Sure.
Dr. Kleinman: You’ll see that the way Marx defines alienation is exactly burnout in primary care physicians. Okay. You get alienated from the product of your work because the quality you would like to produce, you cannot produce. Your hands are tied, as it were, by the system. Okay.
Dr. Ashley: Yeah.
Dr. Kleinman: And I think we — if — I’m older than you, so I can tell you that my generation screwed this up. And how did we do this? Yeah. We were so focused on our own interests in academic medicine and leading health care systems that we allowed economists and health policy people to entirely change the language in which we discussed these issues. Yeah. So the term “patient” began to disappear. All of a sudden we had “clients” and “consumers.” Okay. Right. We had “products.” We had never talked before of care as a product. Okay. But care became a product. And as I’ll mention in grand rounds, the worst thing that happened is: with an economic sleight of hand, we allowed health policy people to claim that they were measuring quality of care when what they were measuring was institutional efficiency.
Dr. Ashley: Okay. Yeah.
Dr. Kleinman: Institutional efficiency is important. Hospitals got to survive. Yeah. But it’s not quality of care. And indeed, at times efficiency can run against quality of care.
Dr. Ashley: Absolutely. How would you define quality?
Dr. Kleinman: Oh, I’m going to do that in grand rounds. Perfect. Perfect. But I’ll tell you right now that I would define it in terms of the time and quality of the doctor–patient relationship. Okay. Measuring communication. Yeah. And for the first time — I’m 84, so I won’t be here to see the results, but you will, I hope so — for the first time, AI is going to help us measure all these things.
Dr. Ashley: I was gonna get to –
Dr. Kleinman: AI is going to help us measure the communication. Yeah. How responses occur, because so much of that communication is responses. Yeah. It’s going to even help us measure the affective tone. Affective tone. Yeah. The emotional tone of a relationship. You know, as long as we use it appropriately and we pay attention to the results, we’re going to have to change.
Dr. Ashley: Yeah. Are you optimistic then about the effect of AI on medicine?
Dr. Kleinman: My belief is that chatbots cannot replace human beings as therapists because they’re algorithms. Yeah. All right. They can do wonderful things in pattern recognition. Yeah. But they’re not human beings responding to you, and they never will be. But they can augment tremendously what we do. So I’m sure that here at Stanford you use AI as medical scribes. It’s fantastic as a medical scribe. Okay. Better than most people who are recording things because it can really focus and give you things. I think AI can measure all these elements of good care. Yeah. And for the first time, we’ll have a measurement. Yeah.
Dr. Ashley: What do you make of some of the data that suggests that even doctors judge some of the answers that an AI provides to patients as more — as showing more empathy?
Dr. Kleinman: Yeah. You know, I’ll tell you why I don’t believe that. Because, um, look into that research and look how AI is tested. Yeah. AI is tested against multiple-choice questions. Okay.
Dr. Ashley: Yeah.
Dr. Kleinman: As soon as you put AI into the actual conversation that a patient has with a doctor, first of all, it goes way down in its effectiveness. Yeah. But it begins to have the same concerns that we have in actual natural communication. So I don’t believe that it’s better at these tests. What I think it does is: it can be a backup. It can be help at the entry point. But let me tell you why I would not have AI take the doctor–patient medical history.
Dr. Ashley: Yeah.
Dr. Kleinman: So we have very good research in primary care that shows that if you look at the history alone — medical history alone — taken by an excellent medical historian, 70% of all diagnoses later proved to be the right ones are made on the history alone.
Dr. Ashley: History alone.
Dr. Kleinman: Okay. Why give that to either a receptionist, AI? You want your best person, right? Right. Doing that. Okay. It’s the same thing with the physical exam. So that’s the other thing that concerns me. Even though I’m a psychiatrist, I always did a physical exam. Yeah. All right. Yeah. At the physical exam, we of course have the technology that is much better at getting at mitral stenosis and ejection fractions than you could possibly do auscultating the heart. But auscultating the heart is only in part getting at the disease. Okay. It’s actually making that skin-to-skin connection — showing you: I’m accompanying you in this. You’re not alone. I’m with you, and I have the expertise to really help you.
Dr. Ashley: Yeah. Okay.
Dr. Kleinman: I think that it’s so sad to see residents across the country who basically have given up on the physical exam.
Dr. Ashley: I just think it’s one of the things that is really important to us here and in our department at Stanford is that while we embrace innovation — and we’re certainly at the forefront of AI and as close to it as anybody in Silicon Valley — that we keep humanity at the absolute center of everything that we do and that human connection. We’re interested in technology where it can bring humans closer together. And that’s one of the reasons why I think you and I are both optimistic about the scribes, because they actually fix a problem that I think technology created. It put a computer in between us — in between the two humans who are most key. I think the AI scribe can now take that computer away and just listen in the background, offer some help with documentation that comes later, but allow then the two humans to make that connection.
Dr. Kleinman: I agree with that. Yeah.
Dr. Ashley: And I think as a traditionally trained — in an old medical school, two old medical schools, Glasgow and Oxford — physical examination was very important to me. And for all the reasons you say, that connection with the family, with the individual, is vital.
Dr. Kleinman: Actually, the UK was very important in setting me on my journey. When I was a Stanford medical student, I spent six months at the National Hospital for Neurological Diseases at Queen Square in London. Yeah. And something happened during that time that stayed with me my whole life, and I wrote about this in The Lancet. I was a very good student, and so I was given — and I was the only student given — the same responsibility as the registrars. And I worked up a case fully neurologically and presented — and this is the case I presented: A 23-year-old consular officer in the British Foreign Service on Malta — a virgin, just married — in his first act of coitus with his wife, also a virgin, blew out an AV malformation, created a dense hemiparesis.
Dr. Ashley: Okay.
Dr. Kleinman: I presented this case to one of the great neurologists of that time, Sir Dennis Williams. Okay. And Sir Dennis went over in detail the neurological exam that I did. He said, “Kleinman, yes. Got it right. Next case.” And I stopped, and I did something which you’ll appreciate from the British tradition of grand rounds. Yeah. I made all the registrars move away from me. Okay. As if I were radioactive. I said, “Dennis, don’t you think we have more to do than just this? Because this is a tragedy. Just think about this — this is an incredible tragedy.” Okay, I’m speaking to them. You know, they can hardly speak without breaking down in tears. Can’t we do something? And then Sir Dennis did something which did two things and instructed me again that he had two sides to himself. He was a great technical neurologist at Queen Square, a public hospital, but he had a Harley Street side from his private practice. He brought them back in and gave them the most sensitive interview and suggested all kinds of things — from having a social worker enter to all kinds of aftercare rehabilitation things. But he never would have said any of those things if I hadn’t provoked him. And I really did provoke him, because he began his response very superciliously — like, who are you? You know. Yes, it’s very like the Book of Job, where God sort of blows away Job and says, “Who are you?” You know, this is what — but he could do that. And that was the second part that made me realize: why didn’t he do that? And that was the social determinants.
Dr. Ashley: Yeah.
Dr. Kleinman: That’s the social determinants of health care. If you paid him, he did it.
Dr. Ashley: Yeah. If you didn’t pay him, he didn’t do it. You spent a lot of time in China. Yeah. Tell me the unofficial story of why you went to China.
Dr. Kleinman: Oh, the unofficial story is an interesting one. I’ve never really written it down fully, but I should. It’s because when I was a medical student here at Stanford, I ran into a beautiful woman who was being courted by three other people. And one of them would become the governor of the state of California, Jerry Brown. And the two others came from extremely wealthy, well-to-do families. One was the scion of the Byrd family of Virginia, and they had horse farms. And the other one was — you would know this — was a family of Scottish jam makers. They made a jam, and they had a castle — Robertson. Yeah. Robbie Robertson’s — they had a castle in Scotland. Okay.
Dr. Ashley: That was stiff competition.
Dr. Kleinman: That was stiff competition. So I got a leg up by learning Chinese because my wife was a China scholar.
Dr. Ashley: Wow. Okay. So that’s what — remarkable. So you started learning Chinese, and then eventually you went to China. That is amazing. I knew there was an unofficial — I didn’t actually know the detail. Amazing. I mean, that’s been such an important part of your writings and your thinking over the years. Where is that today? I mean, there’s no more complicated geopolitical relationship than between the US and China right now. But you’re someone, again, who really can speak to the cultural differences and similarities.
Dr. Kleinman: Minutes before we started talking, I was on my cell phone, and as you know, the government is giving Harvard a hard time right now. And one of the ways it’s doing it is that we have this screening that we must have for all international attendees at any kind of Zoom meeting or any sort of open meeting. We have a real person-to-person meeting. Yeah. And I was just going back and forth about screenings for a big research project I have in China on social technology for elder care. And we have to screen all kinds of people because we’ve been so productive. The National Museum of Science in China is going to do a — has a space for us for a two-year display of our work. Okay. But now we have to have everyone there screened. And so why are we doing this? Well, when I started with China, we were kind of in the same position. I started in Taiwan because we had no relationship with China, right? Relationship was with Taiwan. When China opened up, I went to China with my wife, and I worked there ever till now. There was no reason, actually, politically, for us, in my view, to make China an enemy — a strategic competitor. Yes. Okay. But we don’t have to be adversaries. And even if we are adversaries, I had a model from my colleagues who were my teachers during the Cold War, who kept the relationship between individual Russian and American scientists — and you had this in the UK — going in spite of what the government relationships are. And I think that’s how I see myself now, that I have so many former students who are outstanding psychiatrists and anthropologists in China. They’re in the tops of their profession. They’ve got great research going. I want to support them. And I also believe that in going back and forth, we help each other. Okay. And so I’m deeply connected into the exchange between the US and China. And I think that this is going to become the most important for the world going forward. Since these are the two great economic powers, these are two great centers of science and technology, etc. And just keeping the friendship relationships going, trying to collaborate on things that are not so sensitive politically — that’s what I’m trying to do. I’ve learned an incredible amount from working in China. I’ll just give you one example. When I first went to China, I brought the Western concept of resilience. And my Chinese friends, in the most polite way, disabused me and said, you know, this is a kind of an American Hollywood idea. You know — as you, as a culture, become more mature — they didn’t say that directly, but that’s what they meant — you’ll understand that, you know, life doesn’t always end up well. And what life is basically about is enduring. Learning how to endure. And endurance has joy in it, and it has happiness. But it also has problems and irritations and failures. And that’s exactly right. And so I believe, after taking care of my late wife for 10 years, that our lives are about enduring — learning how to endure, learning how to endure with joy, with momentum, with productivity, etc. But not having the idea that we’re resilient and we’re like a rubber band that you can stretch as broadly as you want, you let go, and it comes back to its shape. When you are doing family care, or even when you’re doing professional care with patients with neurodegenerative disease — almost all of whom are going downhill — it’s like the rubber band was put in the sun for three days and baked. It’s brittle. When you stretch it, it breaks. And we’re all broken in a way. I think even clinicians have a little break in them. And I think that’s crucially important. That makes us willing to be vulnerable. And to say, you know, we really are not sure. We don’t really know. I think at my age, what I’ve become liberated to say is: I don’t know. You know, I really can’t tell you what is going to happen now. There’s certain possibilities here. Let’s see how they develop. Right. You get to a stage in your career, in your life, where you’re able to be honest about your vulnerability. Earlier in your life, you’re not. And I think whole professions are this way. So, not your field, internal medicine. But I think there’s another field, which is neurology, which because of vulnerability is not a great field for caregiving. And if you think of that field — it’s a fantastic field for diagnosis. Right. It’s an intellectually exciting field. But because you have post-stroke patients, ALS, Alzheimer’s, etc., etc., and these patients are elderly and they’re going down — I think it would be difficult for a neurologist to allow that vulnerability to be too open. And hence they don’t get involved in aftercare at all. So that’s really — I’m going to make this point in grand rounds. I had a friend — a really good friend — who was one of the great neurologists in Boston. One of the world’s great neurologists. He made the diagnosis of early-onset Alzheimer’s disease in her complicated case probably 18 months earlier than it would have been made, even if we had used a PET scan at that time.
Dr. Ashley: This is in your wife.
Dr. Kleinman: This is my wife. Yes. And that was his gift to me. Okay. He spent two and a half hours with her, in the most complicated set of examinations. And at the end said, “This is early-onset Alzheimer’s disease.” That was his gift to me. He had nothing — this was a friend — he had nothing to say to me about what to do. What to do next. He’s dead now, and I think he should be here to defend himself. But I think that that was not the way he thought of his field and his responsibility. It ended with the diagnosis. And because there were no treatments. So my suggestion is that we’ve got to figure out how, because neurologists are so critical in neurodegenerative diseases, how can they in fact do those things that are critical for patients around care and what comes next?
Dr. Ashley: And you — I mean, you’ve written so beautifully and touchingly in your book about caring for your wife and this balance between love and care, empathy, and resilience, and the dedication that is required. You know, that is sort of the defining text, I think, in this — in the sense of someone with your background who found himself in the middle of that very situation.
Dr. Kleinman: Thank you for saying that. Yeah.
Dr. Ashley: You know, really — just amazing words. And we’re going to have to wrap up, unfortunately, to get you to grand rounds. One of the phrases that came to mind when I was reading through some of the work that you used — I can’t remember which one it was — but you said, “The wound of knowledge is what anthropology shares with literature.” And I thought that that was a really interesting place maybe for us to end and maybe have you tell us what you meant by that.
Dr. Kleinman: Well, I meant something very straightforward. With three other colleagues, I teach a course at Harvard called Quest for Wisdom: Religious, Moral, Aesthetic. And we have a book coming out from Harvard University Press — will be out next fall — with that title, Quest for Wisdom. Right? And I feel that medicine and anthropology intersect with human experience in part around people’s quest for wisdom. And this is why I feel that AI can do certain things, but it cannot participate in the quest for wisdom. Okay. It can participate in the quest for information. Okay. But not for wisdom. And what is wisdom? Wisdom is what Aristotle called phronesis. Aristotle said there were three kinds of knowledge. There was techne, which is your technical knowledge of your field. There was episteme, which is your epistemological knowledge of how we know. But the most important, he said, was phronesis, which was practical knowledge about how to live a life — how to live a life of purpose — a good life. Okay. He thought that was the most important, and I think that is about wisdom. And that’s where medicine and anthropology also intersect, because we’re intersecting with people, especially at end of life, who are trying to have a wisdom about how to die, about how to live the last part of life. And I think that really good clinicians know that intuitively and contribute toward it. And I think that really good patients actually can teach clinicians about this. So, if you let me just end on this note.
Dr. Ashley: Yeah.
Dr. Kleinman: Henry James wrote a wonderful short story that every doctor should read. It’s called “The Middle Years,” and it’s in a collection of his work called The Aspern Papers. And in this story, he has an elderly writer who’s a world-famous writer who’s dying and being taken care of by a young doctor. And the elderly writer intuits that the young doctor has a secret. The secret is the young doctor also wants to be a great writer. Okay. And so at the end, the elderly patient tries to convey some wisdom, in Henry James’s words, to the young doctor — both for medicine and for writing. And this is what he says. He says: “We work in the dark. We do what we can. We give what we have. Our passion is our doubt, and passion is our task.” So what’s so interesting about this? Our passion is our doubt because everything we’ve learned in medical school, everything you learn as an undergraduate before you become a writer, makes you critically minded. You critique your passion. But at the end, Henry James doesn’t say critique is — or doubt is — your task. Your task is passion at the end. And I think that’s what we want to somehow bring back: an evidence-based, technologically sophisticated medical passion.
Dr. Ashley: Thank you so much. What a lovely note to end on. Thanks for being here at Stanford. Sure. Thanks for everything you’ve contributed to our field, and thanks for speaking at Medicine Grand Rounds.
Dr. Kleinman: Thank you. I appreciate it.