What happened that changed the priest—the revered healer of antiquity—into a person of science? How was the modern doctor made?
Physician is Rajeev Kurapati’s earnest attempt to answer this question and others central to the practice of medicine. For instance, how have the advances of medical technology influenced society’s perception of death? How do physicians balance thinking with feeling when dealing with critically ill patients? How do we meet the needs of patients seeking a personal connection to their doctor in what may seem to be an emotionally deficient medical landscape? Is it possible to overcome some of the compromises we’ve had to make along the way? What is the promise of modern medicine and its limitations? And notably—as medical care becomes more and more digitized and automated, will the medical degree—a universal badge of respectability—continue to hold value?
Dr. Kurapati, a practicing hospital physician, succeeds in gracefully exploring the depths of what it really means to be a doctor—and a patient—at this time in our human history, and his blueprint for building a stronger future of healthcare is an important and valuable one.
|Publisher:||Greenleaf Book Group, LLC|
|Product dimensions:||6.00(w) x 9.00(h) x 0.72(d)|
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THE NATURAL PHILOSOPHER
Fourteenth-century men seemed to have regarded their doctor in rather the same way as twentieth-century men are apt to regard their priest.
— PHILIP ZIEGLER, THE BLACK DEATH
The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.
— SIR WILLIAM OSLER
As a modern doctor, I understand that I have no explanation for some diseases. Why, for example, do kids suffer from cancer? When a mother grieves as she watches her child succumb to a slow death from leukemia, what can I tell her?
As a physician who practices within the limits of science, the best reason I can offer is what scientific medicine provides. To the distressed parent, the mortality statistics may come across as a dispassionate rundown of clinical realities. I might say that perhaps the leukemia is the result of an inherited genetic mutation, passed on unwittingly from parent to child. But this explanation doesn't do anything to ease the guilt that a parent feels when a child is incurably ill. I can give nothing to this mother to console her sorrow-laden heart.
A similar explanation applies to many cancers in adults, particularly when these cancer-causing mutations are exacerbated by lifestyle and environmental causes such as smoking, exposure to chemicals, or too much time in the sun. But for kids, little is known about the causes of these mutations.
Yes, cancer can be caused by tobacco smoke or by an inherited trait, but research finds that most of the mutations leading to cancer crop up naturally. Every time a perfectly normal cell divides, it makes several mistakes when it copies its DNA. These are naturally occurring mutations. Most of the time, those mutations are located in unimportant parts of DNA. That's good luck. But occasionally they occur in a cancer-provoking gene. That's bad luck.
After two or three of these troublemaker genes get mutated in the same cell, they can transform that healthy cell into a cancerous one. What we know so far is that about two-thirds of the total mutations are random, slightly less than a third are due to the environment, and only five percent are hereditary — numbers that vary depending on the type of cancer. Lung cancer, for instance, is largely the result of environmental causes, while the vast majority of childhood cancer is a result of these bad-luck mutations. Of course, people can reduce their risk of preventable cancer by avoiding tobacco, eating well, and maintaining a healthy body weight, but the reality is still that most mutations arise naturally — we have no control over them.
Parents often think that, somehow, they're responsible for their child's cancer, but in actuality these cancers would have occurred no matter what. Even if we do narrow down what causes these genetic aberrations in children, we still fall short of explaining why kids have to suffer from these often fatal illnesses in the first place.
We might also ask why the immune system sometimes attacks our own tissues to cause rheumatoid arthritis, diabetes, lupus, or multiple sclerosis.
On the night she was diagnosed with celiac disease, a young woman in her early thirties lamented:
Tonight was the night of a nervous breakdown, a crying fest. I have never felt such a burden in all of my life. ... I met with the gastroenterologist today, had MORE blood work to confirm there are no other diseases at play with the celiac disease. I was asked to seek a nutritionist. I was also encouraged to find a support group for those with celiac disease ... and then spent an overwhelming amount of time buying stuff I can eat. It finally sunk in today that this will be the norm for the entirety of my life, and [I] cried of frustration trying to explain everything the doctor told me to my husband who is looking at me like I am crazy. I am scared of all the changes ... changes that could mean a healthy wife or days of sickness if we don't do things the right way. ...
Where modern medicine fails to find causes of certain illnesses, evolutionary theories try to fill the gap. Consider the painful condition gout. The best available explanation of why individuals are afflicted with gout is based around the evolutionary theory that humans and great apes have higher blood uric acid levels due to a specific genetic mutation that occurred about 15 million years ago. Uric acid, as an antioxidant, protects against aging and cancer. Logically, natural selection probably led to higher uric acid levels in the blood of our ancestors because protection against cancer and the ailing consequences of senescence are especially useful in a species that lives as long as we do.
English physician Thomas Sydenham, describing how a person with gout spends a restless night in A Treatise of the Gout and Dropsy in 1683, writes:
The patient goes to bed, and sleeps quietly, till about two in the morning, when he is awakened by a severe pain. The pain resembles that of a dislocated bone ... [and] becomes so exquisitely painful, as not to endure the weight of the clothes, nor the shaking of the room from a person's walking briskly therein.
Sydenham wrote with such clarity because he suffered terribly from gout himself. Even the evolutionary explanation of a disease, as logical as it may sound, doesn't pacify the individual's longing to know why they have to suffer.
In its current state, modern medicine remains ill equipped to answer the patient's questions, Why me? Why specifically me? Why should I suffer?
I'm trained to address, from a particular viewpoint based on scientific medicine, how the body works and why some people get certain diseases when others don't. Take strokes, for example. Uncontrolled high blood pressure, the consumption of fatty foods that raise cholesterol, and genes predisposed to atherosclerosis are major causes. But medical science, in its current state, struggles to explain why one individual over another succumbs to a stroke in the first place — why the self-correcting mechanisms of the body fail.
When faced with life-threatening illnesses like cancer, doctors are left to guide patients through a sea of uncertainty. Cancer is complicated, and it's difficult to compare one type or one particular stage to another. Compounding cancer's many consequences, many patients are also frustrated and scared, while family members frequently feel sad, guilty, and helpless. However hard doctors may attempt to coach a patient through this trying time, our efforts often fall short, failing to lend meaningful emotional satisfaction.
The scientific approach is bound by what we can perceive with evidence. Doctors are no different. When asked by a patient, Why did I suffer from a stroke, the answer might be, Because of uncontrolled blood pressure.
And after running few tests, a doctor's response to Well, why do I have high blood pressure? could be, It likely runs in your family.
Why does it run in my family?
Perhaps there's an evolutionary explanation.
Beyond a point, this line of Why me? questioning turns into a metaphysical preoccupation. Such philosophical pursuit is beyond the limits of scientific reason and is thus deemed outside the scope of a doctor's role. The decisions of a scientifically trained physician are driven by facts, not by what he or she happens to believe. When the conversation trails past the boundary of objective proof, the true answers to these questions become unsatisfying to patients: We don't know.
Scientists aggressively pursue the why of many things, although there's a limit to how far down the rabbit hole they're willing to go. When science, in all of its glory, can't explain why we have to suffer from an illness, patients become emotionally exhausted and inwardly defeated.
This is why the most difficult discussion physicians have with patients and their families doesn't involve laying out a detailed vignette of tests or procedures to diagnose an illness, or explaining a complicated surgery. In fact, most doctors find these exercises intellectually stimulating and professionally fulfilling. Instead, the most demanding conversation occurs when a doctor can't find the root of a sickness — when, despite their best efforts, medical professionals are left stumped. Perhaps even more challenging is determining what to say if all treatments fail. The life-altering, and in some cases life-ending, decisions made by patients and their families may literally hinge on the choice of words the doctor uses when delivering this news.
If a patient is admitted to the hospital with no meaningful recovery from terminal illness, a rookie physician might start by asking the patient's family, "What would you like us to do if your mother's heart stops beating or she stops breathing? Do you want us to do everything we possibly can?"
Most family members would, of course, instantly reply, "YES, do everything you can to keep my mother alive," when what they'd actually mean to say was, "Do everything you can to keep my mother comfortable."
After several years of grooming, physicians come to more fully realize the power behind the words they choose, learning how to steer patients and families toward truly digesting the impact of their decisions. Instead of using the phrase "do everything," a physician might delicately elaborate: "We could press on her chest, which could result in cracking her ribs, shock her heart, insert a breathing tube down her throat to put her on an artificial ventilator, or. ..." Usually this approach garners a much different response from the earlier knee-jerk reactions a physician might have elicited. In these instances, patients and families tend to listen intently as the seasoned physician offers an alternative: "If your mother decides she doesn't desire these aggressive, life-prolonging measures, we can let nature take its course."
When there's nothing left to be done by medical science, physicians may attempt to offer varying levels of comfort to grieving families. Still, most take meticulous care not to use phrases like "let God decide" or "the patient will be in a better place." No scientifically trained modern physician explicitly invokes supernatural forces in their treatment plans or deliberately uses the terms spirit or soul in their discussions. To ward off sickness, our medical education trains us to rely only on the abundance of medical knowledge at our disposal. Rather than illnesses being predetermined by any supernatural force, we know that our fates and the fates of our patients are determined by our genes, environments, lifestyles, habits, and decisions.
For the ancient medicine man, though, supernatural forces played the most deterministic role in patients' fates. The village healer of antiquity underwent tedious training to attain certain mystical powers. The medicine man would retire in isolation to "make medicine," that is, to learn the art of healing. Here, he'd fast, pray, and surcharge himself with intense penance or other occult practices to the point of ecstasy. In this state, he'd receive word from the gods through some phenomenon of nature to guide his future.
When he returned to the tribe, he would use his newfound "powers" to cure maladies. One popular belief of pre-medieval times was that illness involved losing part of our soul, so restoration was a key component of healing. The medicine man would enter into a trance to travel to the spiritual world, where he'd then be able to retrieve the soul of the ailing person and return it to them.
Essentially, illness was seen as a sort of personal consequence. Using his mystical powers, the medicine man would first strive to pin down which affliction visited the victim and caused the illness. It was usually a curse or a possession that took the blame. The village healer then warded off the affliction using his occult powers. In modern medical linguistics, we see the relics of this terminology when we regard illness as an invader and our bodies as a battlefield with the use of phrases like "attacked by disease" or "fighting off infection."
The visible, traumatic injuries were treated far more practically (and far more successfully) with bandages, stitches, or splints. When it came to non-traumatic internal ailments, however, our ancients had no clue.
The ancient Egyptians, for example, laid down a systematic method to deal with traumatic injuries. This method was meticulously inscribed in the oldest known surviving medical text, the Edwin Smith Papyrus, dating about 1600 BC.
The physicians classified injuries based on diagnoses they made by finger exploration, then followed a logical treatment plan. They even predicted the outcome of an injury based on the symptoms with surprisingly impressive accuracy. Each case was classified by one of three different verdicts: (1) favorable, (2) uncertain, or (3) unfavorable. A gaping wound in the head penetrating to the bone would be classified as "an ailment which I will treat." Whereas, for a wound penetrating to the bone and splitting the skull with the addition of fever and stiffness (of the neck), the classification shifted to "ailment will not be treated" surgically.
Knowledge of anatomy, the palpable aspect of our biology, was garnered largely by the observation of grievously wounded soldiers and animal dissections. Conversely, diseases that presented without apparent physical trauma were more likely to be diagnosed as being brought about by malevolent spirits or demons. In this case, it seemed like a logical part of the healing process for ancient physicians to invoke the deities of protection.
Primitive people firmly believed disease was sent by the gods as a punishment for moral transgressions, delivered either to the transgressor or to a loved one or confidant. They also didn't believe that sickness struck randomly. Disease was an act of retribution — deception, disloyalty, or theft might explain why someone was sick. With their supernatural beliefs, the medicine man had made-up theories for every aliment under the sun.
Healers often stumbled when attempting to cure diseases, but always played a necessary and important role in offering comfort. In that sense, ancient physicians were able to better perform their duties in this one aspect of care. Since ancient times through modern day, this remains the primary goal of a healer, as observed in 1800 by Dr. Edward Trudeau, founder of a tuberculosis sanatorium: "To cure sometimes, to relieve often, to comfort always."
Because healing was regarded as the outcome of personal, social, and religious beliefs in ancient society, treatment was not merely achieved through the use of therapeutics. Illness was a vital concern for the whole community — a collective suffering. It required rituals that ceremonially cleansed the polluted, offered reparations, and warded off ghosts. Rituals, incantations, and sacrifices were thus essential to this process, as were faith and therapeutics.
Many religions around the world maintain that illness is a manifestation of sin or misdeeds, and ardent followers of these religions continue to believe in such convictions to this day. To most modern doctors, however, disease is recognized as a biological phenomenon concerning only the individual who's suffering.
The result is that suffering can be a lonely fight of one individual against an unknown adversary, a solitary battle in an unchartered territory. When we suffer a stroke or succumb to cancer, physicians don't place blame on or attribute this to a moral trespass or the result of sin. This is true even for doctors who believe there are factors contributing to illnesses beyond the boundaries of human comprehension.
For a doctor like me, there's no room in modern medicine for concepts such as the soul or spirit in curing illnesses. This, however, is a radical departure from how it all started.
* * *
Religion and medicine originally shared a common orientation — both holiness and healing are words adopted from a common Latin origin meaning that which must be preserved intact. Such concepts ensured unity of medicine and faith — physician-priest-philosopher — the curer of bodies and the healer of souls. The delineations between the body, mind, and soul were nonexistent for our forbearers. In Greek philosophy, the righteous mind was a direct reflection of the heavens, and all learning was the path to spiritual fulfillment.
Most physicians in ancient times were temple priests who knew the reasons why things happened in nature, particularly to humanity. Mythological tales of gods and super-humans filled in many of the gaps: Sickness was a consequence of angering the gods, and no one dared to challenge that notion. Appeasing the gods was a way to cope with uncertainties and provided a seemingly convincing path to health and prosperity.
Excerpted from "Physician"
Copyright © 2018 Rajeev Kurapati.
Excerpted by permission of River Grove Books.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Part One — The Priest-Physician,
Ch. 1 The Natural Philosopher,
Ch. 2 Intellectual Hibernation,
Ch. 3 Breaking the Iron Mold,
Part Two — Brave New World,
Ch. 4 The Wondrous Machine,
Ch. 5 Paradigm Shift,
Ch. 6 Emergence of a New Sentiment,
Part Three — Balancing Science and Art,
Ch. 7 Studies, Studies, and More Studies,
Ch. 8 How Mathematicians Changed Medical Practice,
Ch. 9 The Obsession with Measuring the Human Body,
Part Four — The Big Shift,
Ch. 10 How the Heart Lost Its Esteemed Position,
Ch. 11 The Utopia of Curing Death,
Ch. 12 How Doctors Lost the Narrative,
Part Five — Necessary Compromises,
Ch. 13 Price Tags,
Ch. 14 The Unexpected Intruder,
Ch. 15 Medicine's New Mystical Force,
Part Six — The Future Doctor,
Ch. 16 Transcending Limitations,
Ch. 17 Man–Machine Symbiosis,
Ch. 18 How We Made the Modern Doctor,
To My Fellow and Future Doctors,
Notes on Sources,
About the Author,