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Two generations ago, physician was a generic term denoting a medical doctor
licensed to practice healing arts. There was specialization, but it was after World
War II that subspecialization began in earnest, particularly within the academy.
Out in their communities, general practitioners, surgeons, internists, and
pediatricians all considered themselves to be physicians and were licensed to
practice medicine and surgery in all states. They were all doctors,
professionals who commanded comparable respect regardless of any tendency
to restrict their clinical purview. They were considered to be well-educated,
highly skilled, and, above all, motivated to do well by their patients. In postwar
America, doctors were recourse for the ill.
Today, as specialists are laying claim to particular diseases and body parts,
one would be hard-pressed to define physician. Furthermore, doctor denotes
a panoply of professionals. Many if not most holding a doctorate have little to
do with the healing arts. And within the realm of the healing arts, doctorates
abound, as do various licenses designating and sanctioning a range of skills.
Some are licensed to perform procedures that overlap with or are identical to
those permitted by doctors holding medical licensure, such as Doctors of
Osteopathy. Others are licensed for dramatically different practices. Adding to
this menu are a great number of caring professionals who are licensed without
doctoratesnurses and nurse practitioners, various forms of physician
extenders, and all sorts of allied health professionals and sectarian practitioners.
Today, recourse for the ill is a far cry from go to the doctor.
By the Bedside of the Patient is not an exposition on the evolution of
doctoring. It takes as its focus one relationship: the sacred trust between the
doctor of medicine and the person who chooses to be that doctors patient. In
order to examine the relationship, one needs an appreciation of the roles of the
participating doctor and patient and the rules that govern their interaction. None
Reductio ad Absurdum
Every adult knows intuitively what health, illness, and doctor mean. But
these words mean something quite different today than they did a decade ago
and the decade before that. Articulating definitions is challenging. Health is
more than the absence of illness, just as illness is more than the absence
of Introduction:
Humanism
Two generations ago, physician was a generic term denoting a medical doctor
licensed to practice healing arts. There was specialization, but it was after World
War II that subspecialization began in earnest, particularly within the academy.
Out in their communities, general practitioners, surgeons, internists, and
pediatricians all considered themselves to be physicians and were licensed to
practice medicine and surgery in all states. They were all doctors,
professionals who commanded comparable respect regardless of any tendency
to restrict their clinical purview. They were considered to be well-educated,
highly skilled, and, above all, motivated to do well by their patients. In postwar
America, doctors were recourse for the ill.
Today, as specialists are laying claim to particular diseases and body parts,
one would be hard-pressed to define physician. Furthermore, doctor denotes
a panoply of professionals. Many if not most holding a doctorate have little to
do with the healing arts. And within the realm of the healing arts, doctorates
abound, as do various licenses designating and sanctioning a range of skills.
Some are licensed to perform procedures that overlap with or are identical to
those permitted by doctors holding medical licensure, such as Doctors of
Osteopathy. Others are licensed for dramatically different practices. Adding to
this menu are a great number of caring professionals who are licensed without
doctoratesnurses and nurse practitioners, various forms of physician
extenders, and all sorts of allied health professionals and sectarian practitioners.
Today, recourse for the ill is a far cry from go to the doctor.
These psychosocial challenges are not new, just differently framed. Patients
have always had to consider the cost of medical care, but today the
consideration goes far beyond their pocketbooks to the tangled worlds of health
insurance. For nearly everyone, much is at stake, including the possibility of
bankruptcy. Furthermore, patients have to negotiate the administrative maze that
exists between them and their doctor. Finally, the rules of the patient-doctor
interaction are increasingly difficult to capture with a term such as
satisfaction.
By the Bedside of the Patient focuses on the evolution of the role of the
modern physician. Each chapter examines a major postWorld War II transition
in sequence, dissecting the educational, societal, and policy dialectics at work.
Of course, a transition in the role of the physician necessitates a transition in the
role of the patient and in the rules of their coming together.By the Bedside of the
Patient is, thus, an exposition on the dynamics of medical professionalism, the
fashion in which professionalism is reframed in response to pressure and
preconception brought to bear by the community to be served.
Reductio ad Absurdum
Every adult knows intuitively what health, illness, and doctor mean. But
these words mean something quite different today than they did a decade ago
and the decade before that. Articulating definitions is challenging. Health is
more than the absence of illness, just as illness is more than the absence of
health. But how much more and in what way reflects preconceived notions.
Likewise, a doctor is no longer a synonym for medical doctor, and medical
doctor is often thought of as a collection of technical skills. All these
preconceptions are products of culturethe common sense, the comfortable
parlance, the relevant institutions, and supporting structures such as marketing,
government regulations, and insurance schemes. Health, illness, and
doctor are but three of many core concepts of society that are products of
contemporary culture. As is true of all social constructions, they vary from
culture to culture in both a geographic sense and a temporal sense. Todays
iterations are bolstered by the remarkable reach of technology. Health, illness,
and the doctor pop up at all of us all the time on whatever platform we
engage. Health is a commodity and illness a product line to a degree that was
never possible before. And for the doctor, caring for a patient means walking
a tightrope between humanism and consumerism.
The American medical profession of today is a version that bears many more
flaws than attributes from its tendency to accumulate the defects rather than the
virtues of the iterations that came before. Medical humanismthe desire to
bring patient and physician together as people who share the need to define
health and seek its nurtureis the attribute that has suffered most in this
dialectic. That is not to say that the institution of American medicine is not
supporting leaders who proclaim medical humanism almost as a mantra and
claim to be marching to its drum. But its pursuit differs from past generations in
that the means often have become the end. We are convinced that by
doing something we have served our patients, and that simply being there for
them is an antiquated notion not worthy of reimbursement. Medical humanism
demands the profession return to the bedside to practice medicine one patient at
a time The American medical profession of today is a version that bears many
more flaws than attributes from its tendency to accumulate the defects rather
than the virtues of the iterations that came before. Medical humanismthe
desire to bring patient and physician together as people who share the need to
define health and seek its nurtureis the attribute that has suffered most in this
dialectic. That is not to say that the institution of American medicine is not
supporting leaders who proclaim medical humanism almost as a mantra and
claim to be marching to its drum. But its pursuit differs from past generations in
that the means often have become the end. We are convinced that by
doing something we have served our patients, and that simply being there for
them is an antiquated notion not worthy of reimbursement. Medical humanism
demands the profession return to the bedside to practice medicine one patient at
a time with the highest ethical goals. Health care without an empathic
therapeutic relationship might salve disease, but, short of an incisive cure, it
does little to salve the suffering inherent in the experience of illness. To serve as
a physician requires a concerted and ongoing attempt to define the limits of
certainty in a scientific sense and to formulate the boundaries of value in a
collaboration that recruits the patient, the patients community, and the
physicians peer group. There is little about this that can be preempted by
algorithms or guidelines, and very little that can be delegated to others. Medical
humanism demands a doctor-patient relationship that is trustworthy and
therapeutic.
However, such a belief may sound hollow and obsolete today. The social
constructions of both health and illness have grown reductionistic beyond
reason. We are driven to conclusions by metrics that are often obscure, if not
irrelevant to the health of the particular patient. For example, when we learn that
a particular substance reduces the risk of a particular outcome by some
impressive number, say 50 percent, our attention is commanded. But we seldom
ask whether we should care. If the reduction reflects a decrease in incidence in
the outcome from two in a thousand in a year for those who do not take the
substance to one in a thousand for those who do, should we care? And what if
the outcome is not that important in terms of our well-being? Are we supposed
to care then?
We can impute much more to metrics and numbers that relate to illness and
health than humanism supports. Americans walk away from their doctor-patient
relationship focused on their body mass index (BMI), serum cholesterol,
Hemoglobin A1c, bone mineral density, blood pressure, etc., and both the doctor
and the patient consider this a meaningful event. Such metrics are now used to
monitor the quality of care despite science that questions their validity. Its as if
the Dow Jones Index is a valid window on the health of society and
unemployment rates a valid window on the lack thereof. The contemporary
social construction of health, illness, and the doctor has fallen victim to what
Alfred North Whitehead termed the fallacy of the misplaced concreteness. It
is not that the numbers are irrelevant or that the scientific inferences fallacious;
it is that they are incompleteoften sorely incompletewindows into health
and the experience of illness.
2
There is little likelihood that many of us, even those of us who have acquired
the necessary quantitative skills, can sort this out for ourselves when we are ill.
We are all inundated with the noise of marketing, the unforgettable anecdote of
what happened to another, and the vagaries of clinical science. We are seeking
to formulate our values with unreliable measures of benefits and risks knowing
that wed be hard-pressed even if the estimates were reliable. We know from
survey data that most often most of us undertake this decision analysis at
home, relying on our common sense and whatever inputs we garner in our
community. We choose to be a patient when we lack confidence in this
homegrown process. This is the initiation of doctor-patient collaboration in
clinical decision making. My goal in writing By the Bedside of the Patient is to
promote a vision of the role of the doctor that is appropriate to the state of the
science and the notions of health and illness going forward into the twenty-first
century. It is a call for all who aspire to be physicians and all who are in the
process of becoming physicians to be disabused of the notion that technical
skills, be they in decision theory or surgical methods, are all that is necessary to
be a doctor. The more demanding prerequisite is trustworthiness, the
commitment to understand the patients narrative of illness as comprehensively
as one can.
3
Few events in life render us more vulnerable than when we feel compelled to
turn to a fellow human being in quest of wisdom, guidance, empathy, and
concern when faced with the experience of illness. Few interactions have the
potential to be as intimate. For a physician to do justice to the plea of a patient,
to be able to minister to the needs of that particular person, he or she must have
credentials and publications than render me hard to ignore, let alone dismiss. I
cant expect others to be so fortunate in the face of pushback, which is why I
dont consider my life course a role model. At best, its an object lesson for
physicians in the generations that follow.
That is also my intent for By the Bedside of the Patient. I have made every
effort to walk hand in hand with the reader through halls that may not be so
hallowed but were the purview of doctors and the setting for doctor-patient
relationships. I am aiming for the objectivity of an autoethnography, wherein I
describe what I saw, rather than a memoir, wherein I describe what I felt. I am
far more comfortable discussing recent decades, when science can bolster that
objectivity by virtue of more systematic observations of multiple settings that
allow reliably general inferences. I have made every effort to expunge personal
responses and personal relationships from the narrative. In the early chapters,
my success in doing so is far from complete, but such is the nature of anecdotes.
I say this unapologetically. After all, I rely on the memories of some
extraordinary physicians to bolster my approach if not my recall, memories of
my late friend, Mack Lipkin, and the legendary Lewis Thomas.
4
For great and noble are those scientific judgments that serve
the purpose of preserving the health and lives of Thy creatures.
Keep far from me the delusion that I can accomplish all things.
Give me the strength, the will, and the opportunity
to amplify my knowledge more and more.
Today I can disclose things in my knowledge which yesterday
I would not yet have dreamt of, for the Art is great,
but the human mind presses on untiringly.
In the patient let me ever see only the man.
Thou, All-Bountiful One, hast chosen me to watch over
the life and death of Thy creatures.
I prepare myself now for my calling.
Stand Thou by me in this great task, so that it may prosper.
For without Thine aid man prospers not even in the smallest things.
Johns Hopkins pioneered this shift in emphasis in the American academy, a shift
away from the Cartesian model that had held sway since the American
Revolution. Oslers humanism provided balance as medical theory and practice
were being transformed at their core.
Harvard Medical School had contributed many to this pantheon of humanist
physicians long before the merchant Johns Hopkins endowed his university. Not
surprisingly, several of Oslers peers at Harvard shared his devotion to the
humanist tradition and the compulsion to champion the perspective with words
that will ring true as long as there are ill people and committed clinicians.
Francis Weld Peabody was born into a prominent New England family in 1881
and died in 1927, at age forty-six, from sarcoma. After graduating from Harvard
Medical School and training at the Massachusetts General Hospital, he sampled
medical thinking in Berlin, Peking, and Leningrad in preparation for leaving
two indelible marks on Harvard and the world at large: he developed the famous
Thorndike Memorial Laboratory and the Harvard teaching service at Boston
City Hospital, which produced many a major physician/scientist before it
succumbed to Bostons budgetary knife in 1974; and he set a high standard for
the teaching of clinical medicine at the bedside and in the lecture hall. As for the
latter, he delivered a series of lectures to medical students titled The Care of
the Patient. One lecture, published in the Journal of the American Medical
Association on March 19, 1927 (volume 88, pages 87782), is a classic
exposition on humanism in medicine. Most who know it remember in particular
its last line: One of the essential qualities of the clinician is interest in
humanity, for the secret of the care of the patient is in caring for the patient.
Peabody, as with Osler, welcomed the introduction of reductionistic science
into the practice of medicine, a science that probed for the cause of diseased
organs as the window on the cause of the diseased patient. He argues that while
absorbed in the difficult task of digesting and correlating new knowledge, it
has been easy to overlook the fact that the application of the principles of
science to the diagnosis and treatment of disease is only one limited aspect of
medical practice [which] includes the whole relationship of the physician with
his patient. In other words, The treatment of a disease may be entirely
impersonal; the care of a patient must be completely personal, whether in the
office or the dehumanizing milieu of the hospital. With this as his mantra,
Peabody was unwilling to treat only those whose illness conformed to the
medical illnesses that were declared certain and therefore legitimate in that
day.
Of all the pronouncements and prejudices I heard and the primitive clinical
science I witnessed when I started wandering hospital corridors in the 1950s, it
was the strains of medical humanism that captured me most. They shaped the
content of my undergraduate curriculum and the intensity I brought to the
learning. It is my creed as a physician. The first line of the last stanza of the
The Morning Prayer of the Physician is my creed as a physician and the thesis
of this book: In the patient, let me ever see only the man. I intend to take the
reader by the hand and, beginning in the 1950s, travel decade by decade to
observe the varying fate of this tenet. There are golden moments, and there are
periods of fools gold. We have begun the twenty-first century in the latter
period, with the fate of the tenet and medical professionalism hanging in the
balance.