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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.
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.
From the Hardcover edition.