In The Art of Medicine, Toronto Western Hospital’s legendary internist Dr. Herbert Ho Ping Kong draws on his vast dossier of personal cases and five decades as a clinician, to examine the core principles of a patient-centred approach to diagnosis and treatment. While HPK, as he is fondly known, recognizes and applauds the many invaluable innovations in medical technology, as disease and its management grow increasingly complex, he insists that physicians must learn to develop an arsenal of more basic skills, actively using the arts of seeing, hearing, palpation, empathy, and advocacy to provide a more humane and holistic form of care. Aimed at medical practitioners, trainees, aspiring doctors and laymen, the book also contains interviews with more than a dozen of HPK’s patients, as well as short essays that explore the thinking of some 15 of his professional colleagues on the art of medicine.
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The Art of Medicine
Healing and the Limits of Technology
By Herbert Ho Ping Kong, Michael Posner
ECW PRESSCopyright © 2014 Herbert Ho Ping Kong
All rights reserved.
The ART of MEDICINE
* * *
It is more important to know what sort of person has a disease than to know what sort of disease a person has. — Hippocrates
METAPHORICALLY, THE ART OF MEDICINE is a clinic that contains many rooms. In each, a different art is demonstrated.
In one room, there is the art of seeing, diagnosing illness by carefully observing what may be hiding in plain sight.
In a second, there is the art of listening, actively tuning in to the signature rhythms of the patient's body, hearing both what the patient says and, equally important, what he or she may not be saying.
In a third, there is the art of human touch, which includes not only feeling the pulse, palpating the spleen, the kidneys and other organs to make the diagnosis, but may also include simply holding the patient's hand to let them know that you care.
Two other rooms are dedicated to what is often called the Grey Zone. One is for patients who exhibit a range of clinical symptoms that defy simple diagnosis. They are clearly suffering, but there is no agreed-upon name for their ailment. How does the sensitive clinician deal with that increasingly common situation?
The other Grey Zone room accommodates patients who have a definable illness for which there is no specific or reliable treatment. Here, again, the good physician must demonstrate the art of medicine through care management, always bearing in mind the ancient injunction primum non nocere: first, do no harm.
In a sixth room, there is the art of communication — how to elicit vital information, build trust, deliver bad news and inspire hope, even in the most adverse circumstances.
In a seventh room is empathy, understanding the context of any particular illness — its effects on the individual, their life and the lives of their extended families — and expressing that understanding to all concerned.
Another room is devoted to advocacy, asserting the patient's interests within the medical system and, if necessary, beyond.
There are other rooms as well, rooms for thinking outside of the box, treating rare diseases and dealing with epidemics.
For the sake of convenience, I am describing these salons as if they were discrete silos. The truth is otherwise. In fact, the doors to all these rooms connect and, in most situations, the doctor must travel back and forth between and among them, in his or her relentless search for the best answer.
In the process, the good clinician will wear many hats at once — healer, detective, adviser, scientist and artist, deploying the colours of a broad palette.
One must see, listen, touch, communicate, empathize, etc. — yes. But most of all, the challenge of the art of medicine is to integrate what is learned in each of the various rooms and synthesize that knowledge to find the right approach, if not always the perfect answer.
But for the art of medicine, one factor stands paramount: time. Time is the essential ingredient — time not only to win the patient's trust, but the time necessary to take a complete history, conduct a thorough physical exam and carefully consider all the diagnostic and therapeutic options. And time, in many instances, to allow nature to take its appointed course.
In this first chapter, I want to provide examples from my own case histories that illustrate a few of these aspects of the art of medicine in action.
ONE DAY IN TORONTO, AS I accompanied a senior clinician and a junior internist on rounds, we encountered Giuseppe, an 80-year-old Italian who had been treated for cellulitis. However, he had recently developed some new skin lesions on his feet, an indication of infection, possibly the result of staphylococcus, potentially destructive bacteria. Still, the staff wasn't quite sure what was wrong.
We entered his room and found he had three visitors, his wife and two daughters. While my colleagues examined the patient, I made small talk with the family and learned that Giuseppe had been born in southern Italy and had immigrated to Canada many years earlier.
Eventually, I was asked to examine the small lumps on his feet, which were slightly purplish in colour, like blueberries.
"So what do you think?" my senior colleague asked me.
"I think it's probably going to be Kaposi's sarcoma," I said.
Since the early 1980s, Kaposi's sarcoma — named for the Hungarian dermatologist who first described it — has been most frequently associated with HIV/AIDS patients. That form of the illness is very aggressive, often and quickly spreading to the lungs, brain and the GI tract.
But there are several other variants of the disease, including one that historically affects elderly men of the Mediterranean region. I'd seen it before, perhaps two or three times. This strain of KS is less virulent. It can be treated with low-dose radiation, and death is rare.
My comment drew incredulous looks from the medical team. How could I make that diagnosis of a rare illness, based simply on a brief examination of his feet?
The answer was not complicated. It merely required me to integrate what I could plainly see — the "blueberries" on Giuseppe's feet — with my newfound knowledge of the family's history. Both pieces of information were equally vital.
A subsequent biopsy of Giuseppe's tissue confirmed my diagnosis. But again, it was the not-so-casual human interaction — talking to the family about his origins — that had given me the first clues.
SOMETIMES, THE ART OF MEDICINE in diagnosis is based as much on raw instinct as on evidence. Of course, raw instinct is not entirely raw; it's based on experience, for which there is ultimately no substitute. As one mordant Hindu proverb puts it, "No physician is really good until he has killed one or two patients."
One day, a former chief resident of mine, now working in another city, called and asked whether he could refer a case to me. The patient would not be coming for an office visit, so I would have to "examine" him by reading his medical dossier, which would be emailed to me. The patient was a 40-year-old Canadian who had served in Bosnia during the war and been injured. The injury had required a blood transfusion. His file indicated that he was suffering from fever, weakness and a low white blood cell count. Collectively, these symptoms suggested the possibility of HIV/AIDS, but a test for the disease had proven negative. Despite that negative reading, I wondered whether he might, in fact, have HIV/AIDS. I called my former colleague.
"I think you should redo the HIV test," I said.
"Why?" he asked. "He's negative."
"Yes, but he has the classic symptoms of that terrible wasting disease. And he underwent a blood transfusion." Tragically, many HIVA/AIDS victims are infected through the transfusion process.
The test was re-administered and, this time, the result was positive. Sometimes, tests are improperly performed, skewing the outcome. Sometimes, the test is given before the disease is fully manifest, so it is missed. And sometimes, you have to ignore test results and just follow your instincts.
THE GREAT OSCAR WILDE ONCE called proctology "without a doubt, the greatest scientific journey mankind has ever embarked upon." A classic Wildean bon mot, overstated for effect. It's an uncomfortable journey, one many doctors are happy to avoid taking, and many patients are equally happy to have them avoid. But it can literally mean the difference between life and death.
Not long ago, George, a retired 88-year-old businessman, came to see me. He was in rough shape. For six months, he'd been suffering from incontinence, diarrhea and weight loss and, while he had seen several doctors, no one seemed able to figure out what was going on, and thus how to help him.
I took a full history. The most significant medical event was that, 12 years earlier, George had fought a bout of prostate cancer and been treated with radiation. Since then, he'd had regular checkups with his urologist at another hospital, including one only four months before I saw him.
"So what kind of investigation was done following your last visit?" I asked him.
"Nothing," George said.
"I can't believe that," I said. "You've had this condition for months."
"Nothing," he insisted. "I can't go anywhere because of the diarrhea."
"Well, what treatment have you been getting?"
"My family doctor gave me cholestyramine. They said I had gallstones."
I knew cholestyramine to be a drug used to remove bile acids from the system. It also causes constipation.
"So how was that diagnosis made?" I asked.
"I don't know," he said.
"Did you have a colonoscopy?"
I found that very strange, definitely an omission. We then proceeded to do the physical examination, including a rectal probe. There was clear evidence of a rectal mass that could be felt with the fingers. It was blocking the rectum. A CT scan later confirmed its presence. Had it been caught sooner — and it would have been recognized by the simple rectal exam — cancer therapies might have been effective. Unfortunately, this malignancy was too far advanced for chemotherapy or radiation. The only hope was to perform a diverting colostomy, a surgical procedure that allows stool to bypass the blockage caused by the tumour.
We still have our fingers crossed for George's recovery. In the meantime, his quality of life improved dramatically, following the removal of the obstruction by the colostomy.
SOME YEARS AGO, I WAS privileged to work with the young David Naylor, a remarkable epidemiologist who went on to found the Institute for Clinical Evaluative Sciences, housed on the Sunnybrook Hospital campus. Later, he became dean of medicine at the University of Toronto, and later still president of the university. A major proponent of evidence-based medicine, Naylor nonetheless acknowledges its limits, particularly in respect of the large area of medicine known as the Grey Zone.
As Naylor wrote in a 1995 piece in the Lancet, in an "era of chronic and expensive disease, there are no vaccines yet for atherosclerosis, cancer, arthritis or AIDS. Until ... molecular biology pays more concrete dividends we shall be muddling along with what Lewis Thomas characterized as 'halfway technologies.'" Clinical medicine, Naylor wrote, "seems to consist of a few things we know, a few things we think we know (but probably don't) and lots of things we don't know at all."
It is precisely within this large Grey Zone that many physicians must practise. Too often, there is no clear path to diagnosis and treatment. Every step, every decision, is an exercise in uncertainty. An aggressive approach to medical tests might well provide the answer we are seeking. But it also might confuse the issue, providing information that will take us in new and ultimately futile directions. As Naylor says, paraphrasing the great Sir William Osler, "Good clinical medicine will always blend the art of uncertainty with the science of probability."
One patient of mine — Claude, a 40-year-old man from Quebec — provides a case in point. He had been previously diagnosed with inflammatory bowel disease and, while it was under control, other problems developed, including a swelling under his lower jaw. A biopsy uncovered fibrous, non-cancerous tissue, but he was also losing weight and was slightly anemic.
Then, a new complication arose — severe abdominal pain. His family doctor said it was a hernia and sent him to Toronto's Shouldice Hospital for surgical repair. But after they opened him up, they discovered that instead of a hernia, Claude had a large swelling in his lower abdomen. No wonder he was in such pain. His hemoglobin count was down to 100 (the norm is about 120). My own exam confirmed a tender, football-sized mass in his lower abdomen.
But was this cancer or part of a systemic inflammation his body was experiencing? Cancer would take us in one treatment direction, inflammation in another. For several reasons, including an erythrocyte sedimentation rate (ESR) level of 150 and a slightly elevated C-reactive protein count — indices of serious inflammation — we decided to set up a therapeutic trial.
Most such trials, of course, involve hundreds if not thousands of patients. Any verdict about efficacy is based on the results that affect a significant statistical sample. We did not have that luxury. Our sample was one, Claude — thus giving rise to the phrase an "n of 1" trial. The drug we chose was prednisone, a corticosteroid proven over the past six decades to successfully reduce inflammation, though not without some pernicious side effects, including suppression of the body's immune system.
If we were on the right track, then Claude's high ESR and C-reactive numbers would drop, his mass would shrink, his pain would disappear or substantially abate and his hemoglobin would rise.
We started with a large daily dose of prednisone — 60 milligrams — and added methotrexate to curb the steroidal side effects. In two weeks, the fibrous mass had shrunk to the size of a baseball. In six weeks, all our benchmarks for success had been met — general well-being, weight gain, higher hemoglobin count, dramatically reduced mass size and much lower numbers for ESR and C-reactive protein. Over the course of a year, Claude made a complete recovery.
MOST PHYSICIANS, I'D LIKE TO THINK, are naturally empathetic. It is one of the principal characteristics that motivate many of us to choose medicine in the first place — the instinctive compassion we feel for those who are burdened with disease, and the desire to help them improve or at least come to terms with their illness.
At times, given the weight of caseloads and other demands on our time, the empathy factor can fade to the margins. In fact, there is research to suggest that medical students become less empathetic as they move through the system, a consequence, perhaps, of the growing pressures they face.
And yet for many patients, a display of empathy is what they most need — evidence that their attending doctor cares deeply about their condition and their well-being. One potent supplement to empathy is advocacy, becoming the patient's champion and using resources available to facilitate access to specialists, medical tests, drugs, other therapies and insurance. All these are time-consuming activities, to be sure, but a vital part of the art of medicine.
Kham V., a Canadian originally from Laos, worked as a chef in a Japanese restaurant when, at about the age of 33, he developed Behçet's disease. A rare disorder (named after Turkish dermatologist Hulusi Behçet, who first described it in the 1920s), it inflames the body's blood vessels. For Kham, the first signs of it were painful mouth sores. He was successfully treated for that but, a decade later, developed blood clots in his legs.
He was anti-coagulated with Coumadin, and he recovered, but the clots reappeared on two other occasions, over a period of three months. In fact, they developed despite a very high dosage level of the drug. So we switched to blood-thinning therapies, moving to heparin, which must be administered daily by injection, subcutaneously.
On a chef's modest salary, Kham was not prepared financially to absorb the $12,000 per year cost of the drug. Indeed, to economize, he started to cut back on his injections, first to three times a week, then to once a week. Very quickly, he developed a large, vasculitic leg ulcer — so large, in fact, that the surgeon suggested he might have to sever part of his limb, in order to save him. Fortunately, that wasn't necessary. We quickly returned Kham to his regimen and he slowly recovered.
But the ongoing financial burden was onerous. At that point, I consulted with my chief resident and we agreed to approach the French drug manufacturer, Sanofi-Aventis, and ask them to make a significant donation. Every three months — for the past 12 years — I write a letter requesting a refill, and every three months it arrives in the mail.
The quid pro quo is that we invited Kham to donate his services to medical education. We have used his case extensively in teaching medical students and residents. Making dozens of trips to the hospital, Kham has allowed himself to be interviewed and examined, to demonstrate the clinical features of recurrent deep-vein thrombosis and life-threatening vasculitic ulcer.
Excerpted from The Art of Medicine by Herbert Ho Ping Kong, Michael Posner. Copyright © 2014 Herbert Ho Ping Kong. Excerpted by permission of ECW PRESS.
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Table of Contents
Foreword Catharine Whiteside, M.D., Ph.D. ix
Foreword Dr. Lisa Richardson xiii
Preface Michael Posner xvii
Chapter 1 The Art of Medicine 1
An Administrator's Perspective Dr. Michael Baker
Chapter 2 Starting Out 119
A Psychiatrist's Perspective Dr. David Goldbloom
Chapter 3 Lessons of the Montreal Years 45
An Educator's Perspective Dr. Brian Hodges
An Infectious Disease Specialist's Perspective Dr. David McNeely
Chapter 4 The Art of Seeing 71
An Internist's Perspective Dr. Rodrigo Cavalcanti
An Ethicist's Perspective Dr. Peter Singer
Chapter 5 The Art of Listening 99
An Internist's Perspective Dr. Daniel Panisko
A cardiologist's Perspective Dr. Mansoor Husain
Chapter 6 The Art of Palpation 123
A Radiologist's Perspective Dr. Anthony Hanbidge
A Rheumatologist's Perspective Dr. Lori Albert
Chapter 7 Entering the Grey Zone 147
A Scientist's Perspective Dr. Moira Kapral
A Respirologist's Perspective Dr. Matthew Stanbrook
Chapter 8 Further Excursions in the Grey Zone 173
An Internist's Perspective Dr. Stephen Hwang
Chapter 9 Thinking Outside the Box 191
An Internist's Perspective Dr. Angela Cheung
A Cardiologist's Perspective Dr. Matthew Sibbald
Chapter 10 Of Fevers, Epidemics and Epidemiology 217
An Internist's Perspective Dr. David Frost
Chapter 11 Confronting Rare Diseases 243
Chapter 12 Epilogue 259