The Uncertain Art: Thoughts on a Life in Medicineby Sherwin B. Nuland
—What does the first Hippocratic Oath really mean?
—What happens when knowledge comes before we're ready for it
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Long-time physician Sherwin B. Nuland presents a provocative and stimulating collection of stories illustrating the vagaries of medical practice over the years. Among the fascinating and probing questions that Nuland investigates are:
—What does the first Hippocratic Oath really mean?
—What happens when knowledge comes before we're ready for it?
—Why does major surgery using only acupuncture work?
—Is there really sympathy between the organs of the body?
—What happens when someone yells, "Is there a doctor in the house?" and you are the doctor?
—What goes through the mind of a heart transplant candidate who doesn't make it?
In these essays reprinted, for the most part, from the American Scholar, Yale clinical surgery professor Nuland ponders various aspects of the practice of medicine and patient care. Opening the collection by urging his colleagues toward introspection and self-awareness, Nuland stresses that doctors make life-and-death decisions based on their own emotions, strengths, insecurities and very human needs. In another essay concerning human cloning and manipulating DNA to achieve human immortality, the author suggests we put the brakes on radical technologies whose uncertain consequences we have only begun to contemplate. On a trip to China, Nuland is intrigued by a thyroid operation performed under acupuncture where the patient was wide awake and smiling and suffered no anesthetic aftereffects after a two-and-a-half-hour excavation of her neck. Elsewhere, in an essay on grief written shortly after 9/11, Nuland calls Islamic fundamentalism "a sickness of the soul," and in the book's final entry, he himself grieves over a cardiac patient who died while waiting for a new heart. Although solid and perceptive, these essays are also occasionally flowery and verbose, and do not offer the rich insights of the author's bestselling How We Die. (May)Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.
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THE WHOLE LAW OF MEDICINE
Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals, cooperate.
The First Aphorism
attributed to hippocrates, c. 400 b.c.e.
It has long been accepted that a considerable portion of the body of writings credited to Hippocrates was in fact authored by others, in the two centuries following his death. But until recent decades, scholars remained convinced that reliable criteria were recognizable by which at least a certain core of the material might still be identified as his own. They set this group of texts off from the rest by calling it “The Genuine Works of Hippocrates.”
English translations of these central teachings were inadequate and incomplete until the mid-nineteenth century, when the Sydenham Society of London commissioned the Scottish surgeon Francis Adams to provide a definitive edition. Published in 1849, the two-volume result of Adams’s efforts—naturally called The Genuine Works of Hippocrates—took its place as the authentic historic record.
During the last century, cracks began to appear in the supposed evidence by which some of even these “genuine” works had been certified into the canon, but the short book of pithy clinical maxims known as The Aphorisms held out longer than most. As recently as 1934, members of America’s first think tank of medical historians, based at Johns Hopkins University, could write in their Bulletin: “It is almost universally agreed that among the many Hippocratic writings, the Aphorisms are genuine.” The editors of the journal then went on to point out something that remains true to this day: “They are also undoubtedly by far the most popular books; printed, translated, and commented upon endless times, they were the physician’s bible for many centuries.” And in a little aside, they added the surprising—at least to me—statement that the introduction into English of the very word “aphorism” is owed to this “anthology of medical truths.”
Nowadays, finding a historian who agrees that The Aphorisms was actually written by the legendary Father of Medicine is as unlikely as finding a clinical physician who agrees that all of the 422 nuggets of advice contained in its pages are “medical truths.” Though enshrined in the tradition of almost two and a half millennia as the First Aphorism of Hippocrates, the words of this chapter’s epigraph, for example, were probably never uttered by their putative author. A few reasonably dependable bits of information are known about the great man’s life: he was born about 460 b.c.e. on the Greek island of Cos; he was probably an itinerant physician; he seems to have been a leader in the formation of a school for the training of young doctors. We know little more than that, and what we do know most assuredly does not include hard evidence that Hippocrates left any identifiable corpus of written work. As for the clinical pearls of wisdom: although some of them are nothing less than astonishing in the accuracy of their perceptiveness and the wisdom of their recommendations, others are so bewilderingly at odds with simple observation that they seem to have been inserted to keep the reader awake by making him laugh. What, for example, is a doctor to do with such pronouncements as “The bald are not subject to varicose veins” and “Stammerers are particularly liable to obstinate diarrhea”?
All this having been said, the First Aphorism continues to stand by itself as a model of, of—well, of precisely that: the perfect aphorism, well deserving of its priority, which, if that 1934 issue of the Bulletin of the Institute for the History of Medicine is to be believed, places it squarely as being indeed the first of all time. An aphorism should stand by itself, without reference to anything preceding or following it, and it must express a timeless truth in a brief burst of sagacity, requiring no editorializing, interpretation, or further comment.
But of course, the more memorable the aphorism, the more likely it is that editorializing, interpretation, and further comment will be its fate in perpetuity. Particularly when the epigrammatic saying incorporates principles that have guided a profession for two thousand years, as this one has, there is no end to the ways in which it is likely to be studied, discussed, and anatomized. Add to this its source in a classical language spoken by very few of those who would dissect its lesson, and the result is countless pages and perorations that have never added an iota of substance to the original.
In this it resembles the Hippocratic Oath, which has also been the object of much learned discourse and even a good deal of fretting, especially in today’s ferment of anxious debate over assisted suicide, abortion, and other ethical issues for which the profession and the public seek a precedent in time-honored codes of behavior, or at least a guide to immutable principles of morality. Ethicists and others have worried the Oath as a dog worries a bone, craving the meat and marrow of some eternal principia with which to strengthen the ancient bonds of professional obligation. Yet even as their elders cleave to the Oath, recent classes of graduating medical students have not hesitated to “bring the text up to date” or “make it relevant to our needs” in order to reflect whatever acceptable current values they are willing to espouse in this self-absorbed era of moral relativism. Like scripture, the Oath is quoted by both sinners and saints. For every traditionalist, there is a revisionist who claims it to be interpretable or amenable to alteration as needed, often in ways different from what its original words would seem to imply. There is even a body of historical opinion holding that in its day, large sections (or perhaps all) of it were ignored by most physicians. But here the case of the First Aphorism differs markedly from that of the Oath: though it has been the subject of plenty of discussion, there is little disagreement over the aphorism’s intent.
Clearly, the First Aphorism was written by one or more wise and vastly experienced physicians, but its purpose was not to provide a moral precept. It was meant simply as a statement of what it is like to try to care for the sick. Not only does the aphorism avoid preachiness, but, quite to the contrary, it is a testimony to the humility with which a doctor should approach his calling and a declaration of the profession’s delineated capabilities. Its subtext is the very basis upon which this book has been given its title: the uncertainty inherent in the art of medicine.
In my view, the First Aphorism should be read to every beginning class on its initial morning of medical school. A student is then still a “civilian,” one who has not yet absorbed so much as a particle of that fluctuating mix of science and art of which the profession has always consisted. From that hour forward, the values of the guild will soak ever more deeply into his or her mind and self-image, so that the end of the first academic year finds a young person vastly transformed. It would be good for that transformation to start with the First Aphorism—at the very least, a dawning of insight into what must be borne in mind if the task ahead is to be accomplished with scientific skill and humanity both, and with tolerance for the Art’s limitations as well as one’s own. It would be good, too, if the aphorism were to be reread yearly or even more often, that it might fix itself into the perceptions of the developing doctor so steadfastly as to remain ever in the forefront of thought. Like the Talmudic sage Hillel’s response when he was challenged to summarize his religion while standing on one foot—that one never do to others what is hateful to oneself—the First Aphorism is medicine’s whole law; the rest is commentary. Having learned that law, one should (as Hillel enjoined his challenger after both feet were back on the ground) go and study it.
The thing needs to be parsed. In doing so, I will deliberately avoid certain venerable scholarly differences of opinion about the proper translation of a few of the aphorism’s words, relying instead on the English as it appears in the original Adams publication, which, with slight variations, is the commonly accepted version. At first, I will restrict my comments to the statement’s first sentence. Life may be short, but I plan to make mine long enough to get back to that vastly important second section in a later chapter.
Life is short, and the Art is long. Although life expectancy is currently well more than twice what it was during the golden age of Greece, it will never be endowed with years enough for anyone to master the vast expanse of medical knowledge, or even that part of it sufficient for an individual doctor to care for all of his patients. In every era, some people live well beyond their expected span; Hippocrates himself seems to have been one hundred when he died in approximately 360 b.c.e. Yet even at the barest beginning of Western medicine’s history, it was recognized that no man’s lifetime was sufficient to learn all that was required.
In view of what comes next, it is pertinent to point out that some commentators have read these opening words in a different way, taking their meaning to be that medicine demands a certain amount of time to exert its healing powers, but the patient’s life may be short once disease strikes. Either way, there is a realization here of the inconsistency between the time required and the time available, a factor over which no physician has control.
The occasion fleeting. Here, too, the focus is the urgency that exists in most medical situations, even those that are not acute emergencies. There is a finite period in the course of a disease (and for some, “fleeting” is indeed appropriate) when it is amenable to curative treatment. Although the window is considerably larger now in the early twenty-first century, it is well known that timely diagnosis is often a greater factor in outcome than is the treatment per se. When a patient presents himself to the physician beyond a certain point in the evolution of a disease process, the opportunity for a satisfactory result is diminished or lost. When statisticians in the Department of Health Studies at the University of Chicago pointed out in The New England Journal of Medicine that evaluations of cancer mortality in the United States between 1970 and 1994 demonstrated a “lack of substantial improvement over what treatment could already accomplish some decades ago,” they pointed out that the best therapeutic methods and prevention must be accompanied by “access to the earliest possible diagnosis.” Looking from the opposite perspective, I have in my own career witnessed a decline in the long-term mortality rate of women with breast cancer, attributable for the most part to the fact that patients began in the late 1970s and early 1980s to be diagnosed at an earlier stage of the disease, thanks to increased public discussion and the widespread introduction of effective mammography.
Preach though he may about the necessity of early discovery and intervention, the physician may find that achieving this goal in an individual case is, by and large, beyond his control if his patient is not alert and informed. Even then, some pathologies are characterized by onsets so insidious that clues are absent until the situation is beyond retrieval. A man or woman presenting late in the course of a disease demands and deserves great efforts to heal, but the ineffectiveness of those efforts is not commonly a reflection of the quality of the care that has been given. Though physicians tend to flagellate themselves—and one another—over their inability to salvage a delayed presentation of sickness, such perceptions of personal failure are usually erroneous. Just as physicians must constantly admonish one another to seek the most subtle beginnings of disease, they must also forgive themselves when timing or circumstances frustrate their best intentions.
Experience fallacious. Though a physician’s experience is, after science, his most important diagnostic and therapeutic armament, he should never allow himself to forget for a moment how it can lead him astray while caring for any one sick person, whose situation may present riddles that differ from everything else he has learned at the bedsides of so many others. The issue of individual variation in patterns of illness has been addressed by authorities as widely dissimilar in perspective as Voltaire, the French literary savant, and Claude Bernard, the first of the great modern physiologists. Voltaire, addressing the insistence of some that a sickness be given the same treatment in everyone in whom it is discovered, wrote in 1723, “What they overlook is that the diseases which afflict us are as different as the features of our faces.” In his seminal mid-nineteenth-century guide to physiological research, Introduction to Experimental Medicine, Bernard made the same observation, based on his investigations into human biology: “A physician . . . is by no means a physician to living beings in general, not even physician to the human race, but rather, physician to a human individual, and still more physician to an individual in certain morbid conditions peculiar to himself and forming what is called his idiosyncrasy.”
Experience may be misinterpreted, misremembered, and even misused, though unwittingly. Statistics, which are the recorded and combined experiences of many disease encounters, suffer from their own disabilities, including on the one hand the blending of categories of patients whose problems do not belong together, and on the other the omitting of the experiences of certain types of patients in a well- intentioned attempt to avoid precisely such inappropriate admixing. For any specific person suffering from a specific disease in a specific setting being treated in a specific environment by a specific doctor, a statistic is nothing more than a statement of relative probability.
Judgment difficult. For any bedside doctor, these two words are the distilled essence of the First Aphorism and, in fact, of all medical care; everything coming before them is merely prologue. Judgment is focused on the immediacy of the moment; the distinctive evolution of the disease in one distinctive human being leading up to that moment; the facts of the pathological process as they reveal themselves, also at that moment; the inferences drawn from the facts; the patient’s emotional and biological responses to the illness; the circumstances in which the encounter occurs; and the personal background brought by the physician to this critical instant in his patient’s illness—and in his own life.
Aside from considerations of experience and knowledge, not much attention has ever been paid to the final factor in the foregoing list, yet none of the others (excepting only the pathology itself) exceeds it in importance. Although a great deal has been written about the so-called doctor-patient relationship, I have encountered very little recognition of the reciprocal nature of that relationship—of its essential interdependency.
Three decades ago, I cared for an astonishingly perceptive university chaplain during the course of a protracted hospitalization, at the conclusion of which he made a number of trenchant observations about the medical team. Among his comments was one whose validity I have had plenty of opportunity to confirm since that time. “We patients,” he said, “do more for you doctors than you do for us.” What he was recognizing, of course, was our outsized need for the emotional rewards not only of overcoming disease but also of being healthy and strong while those who are dependent on us are diminished by their illnesses. The effect on medical care of the relationship between power and impotence is an unacknowledged thread that runs through the practice of the Art, as is our insatiable appetite for extravagant gratitude and the constant burnishing of our self-image. And these are only a few of the unstudied influences with which every linkage between doctor and patient is imbued.
There is little significant literature examining the psychology of those who choose medicine as a career, much less one or another of its specialties. Few have seriously asked, “Who are these people, and what drives them?” Whatever distancing or objectivity has been introduced into medical practice by the current array of instrumentations and intradisciplinary fragmenting, it is human beings who make the ultimate decisions about diagnosis and therapy. And they make those decisions against the background of their own emotions, needs, insecurities, strengths, strivings, and—even in these days of Freud bashing, it must be said—their own countertransferences to and identifications with those whose lives are in their hands.
Self-awareness has never been the strong suit of those who choose to become doctors. When so much fuel is readily available for stoking the fires of ego, there is little inclination to apply it in raising the candlepower of the searching light that might illumine the inner man or woman. I would venture to guess that the percentage of unexamined lives in my profession is shockingly high. Yet the rewards of identifying and facing one’s own motivations and tremblings are enormous. I refer here not to some idealized hope of overcoming what is undesirable in ourselves but rather to the more practical wish that physicians might pursue self-knowledge with a distinctly clinical aim in mind: to help us understand what can be brought to consciousness about why we incline one way or another in the choice of pathways along which we send our patients. Judgment is difficult enough without adding to the problem by further obscuring the dimly recognized or unspoken motives that may influence it. As the aphorism says, the Art is long, and there is little we are able to do about the shortness of our own lives. But we can deepen our understanding of ourselves, and in this way deepen our ability to help our patients, and add breadth to the value of our days.
Doctors expect a great deal of themselves. Patients expect a great deal of their doctors. As has been true since the time of Hippocrates, some of those expectations are unrealistic, while others might best be met by a more frequent inward focus, a bit more understanding of one another, and a mutual recognition of what is possible and what is not. This, I believe, is the ultimate message in the First Aphorism and the reason it will always be the whole law of medicine. We should enjoin ourselves—doctors and patients alike—to go and study it.
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Meet the Author
Sherwin B. Nuland, M.D., is the author of numerous books, including Doctors: The Biography of Medicine; The Wisdom of the Body; and How We Die: Reflections on Life's Final Chapter, which won the National Book Award.
Michael Prichard has recorded well over five hundred audiobooks and was named one of SmartMoney magazine's Top Ten Golden Voices. His numerous awards and accolades include an Audie Award and several AudioFile Earphones Awards.
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