The Artful Science of Medicine

Forward

This booklet was inspired by many of the teachers I have encountered in my medical education. Since 1979, I have had the privilege to work with medical students, nurse practitioners and family practice residents. My observations of the strengths and weaknesses of their clinical training, as well as my own, prompted me to write about how the process got that way, and how it can be improved. The same frustrations, challenges and joys have inspired some of my poems. What follows is my attempt to find a cohesive pattern amid the turmoil. I begin with the premise that modern medicine is based on science. How that assumption shapes the attitudes and interactions of physicians and patients forms the next part of the booklet. Lastly, I offer a model for us to strive for: artful medicine. This ideal may be even harder to realize in an era of Managed Cost (not Care) medicine.  Special thanks for their invaluable assistance and encouragement are due to my colleagues Paul Brenner, MD, Jim Gude, MD, Suzanne Kohl, RN FNP, Amy Shaw, MD, and my editor Carolyn Greenlee. Finally, I would like to thank my patients, who as group and individually, continue to remind me how important it is to continue to learn and to question certainty. (Clearlake, California April, 1992 and December, 1997)

In the late 20th century a hole in the ozone layer appeared over the Antarctic. Normally, this layer of ozone in the upper atmosphere filters out ultraviolet radiation. Since ultraviolet radiation causes skin cancer and cataracts, most mammalian life, if polled, would appreciate being protected. Ozone itself is a highly poisonous gas, so it's just as well that it usually stays high in the sky. The hole in the ozone is caused by the use of fluorocarbon propellants, which are generally considered inert. This I believe is a symbol of our times: the harmless chemicals destroying the poisonous gas, letting in the carcinogenic radiation.

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To many modern thinkers, traditional religious organizations seem out of touch, their language archaic, their concerns naive, and their prescriptions for behavior needlessly restrictive. Such educated people believe in Science. Religions appear subjective, prejudiced (the Chosen People), vague, inherently dependent on personal belief and untestable. Science is seen as objective, unbiased, predictable, impersonal, and provable. Unfortunately, the actual process of scientific experimentation, theorizing and consensus doesn't live up to those lofty expectations.

Objectivity in science is based on a belief in the impartiality of the observer and an unequivocal process of perception. In this Newtonian world, objects behave predictably; the role of the experimenter is to passively record observations. However, the deeper we look into the solid masses of Newtonian physics, the more empty space we find (literally). When fundamental questions are tested, results can be confusing, conflicting and controversial. The Big Bang might be causing a reverberation in our radio telescopic ears. Cold fusion might occur in heavy water on palladium electrodes. Z particles, quarks, black holes and other fanciful constructs of theory explain some of the observations, but are difficult to prove in any ordinary sense of the word. Trying to explain wave/particle duality to a non-believer is like explaining the Trinity to an agnostic.

An honest history of science is full of partisanship, bickering, struggling for power and prestige and the suppression of new ideas. Insights often occur serendipitously: Kekule discovered the structure of benzene in a dream about snakes, penicillin was an "accident" in Fleming's lab, Schalow invented the laser while speculating about properties of coherent light. True paradigm shifts in scientific thinking require the development of a group of influential scientists who promote the radical new theory. This social process is well described in Thomas Kuhn's The Structure of Scientific Revolutions: the world of Science is populated with High Priests, heretics, true believers and radicals. Current scientific truth is a gospel espoused by people with axes to grind. At its best it is an evolving approximation of consensual reality.

Since science hasn't yet arrived at ultimate unchanging truth, uncertainty is a necessary component of scientific theory and practice. One of the radical changes in science took place during this century with the introduction of the theory of Relativity. Suddenly, the observer's location influences the observation; time dilates or constricts depending on the observer's relative velocity. Space curves toward objects of great mass; matter and energy are interconvertible, as are space and time.

Trying to understand the universe on a smaller scale proves just as difficult. Even simple measurements defy common sense: trying to measure either the position or the velocity of an electron precludes making the other measurement. The "objects" that we observe are inextricably tied to the act of observation and to the observer. Our best descriptions of matter invoke probabilities, tendencies, ranges of likelihood. The only certainties are that light travels at a constant velocity and that matter/energy is neither created nor destroyed.

Although such a paradoxical universe may seem bleak, Capra(1) points out the similarities between probabilistic physics and the ancient Chinese philosophy of Taoism: there is an inherent harmony amidst the flux, travelling between polarities which are complementary. What we perceive as static may be a standing wave of continuous motion. There is an interconnectedness of all things even though individual activity seems random.

For those who seek meaning in these patterns of probabilities, there is a cosmic connection to man's search for his place in the universe:

"The fate of individual human beings may not now be connected in a deep way with the rest of the universe, but the matter out of which each of us is made is intimately tied to processes that occurred immense intervals of time and enormous distances in space away from us. Our Sun is a second- or third-generation star. All of the rocky and metallic material we stand on, the iron in our blood, the calcium in our teeth, the carbon in our genes were produced billions of years ago in the interior of a red giant star. We are made of star stuff."(2)

Physicists' Wedding Prayer
Dear Organizing Principle
convey to these assembled humans
Your ultimate rationalization.
Lift their aspirations and recharge their energies
to witness this rare phenomenon:
Man and woman, separate and distinct
seek to unite into a higher energy state,
like two electrons matching spins,
they jump into a new sphere of possibility.
Antithesis of entropy,
we marvel at your courage:
in the face of inevitable chaos
you pursue order and predictability.
Bless this union of individuals
with the potential for renewal,
not only of the species
but also of imagination,
shared joys of discovery,
and emotional forces that bond.
Let them surpass
the shackles of convention--
finding in their mutual affection
grounds for generous behavior
toward each other, and all others;
restating in their daily example
the optimism of the big bang
sending all matter spinning
into an empty space
where stars could be born.
We ask this in the name
of Newton, and Einstein
and Heisenberg,
all men.

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The paradoxes in relativity and quantum theory may have revolutionized thinking about physics, chemistry and astronomy, but what implications do they have for biology and the social sciences? Have there been any comparable revolutionary ideas in those fields?

Modern biology was shaped by the ideas of Darwin, Mendel, Virchow (cell theory), Pasteur and Bernard. Mendel provided a mechanism, the recessive gene, that explained Darwin's concepts of natural selection and evolution. Locating the gene as part of the cellular nucleus connected the process of evolution from single-celled organisms through man. Pasteur and Bernard began to study the relationships between the micro-organisms and host organisms in both normal function and disease. Pasteur also established that biological processes were mediated chemically (fermentation).

In recent times, the structure and molecular biology of the gene have given us better understanding of the mechanisms of mutation (which drives natural selection) and the pathophysiology of inborn errors of metabolism, viral infections, and ionizing radiation. We now are capable of elucidating the entire sequence of nucleotides of the human genome.

Yet there are many areas of biological science that are not so easily explained. The tools of mechanistic science limit the kinds of questions biologists can answer (or even ask). When a fertilized egg divides, it produces two identical cells, each with a potential to form a complete individual. After several more cell divisions, however, the capacity for totipotency is lost; successive cells are specialized and will form only certain types of tissue. In the developing embryo, cells migrate, divide and stop dividing according to a complex choreography which culminates in an integrated individual. How the appropriate genes are switched on and off to allow groups of cells to accomplish this feat remains a mystery. The solution is not likely to be a linear sequence, but an understanding of the entire interacting system. "Biologists know the alphabet of the genetic code but have almost no idea of its syntax"(4)

When a wound heals or a limb regenerates, the embryological process recurs on a limited scale, seeming to follow a template to recreate the original design. These processes are no mere recitation of genetic ABC's; they are poetry.

The reductionism of narrow science leaves many unanswered puzzles: why do evolutionary irrelevancies exist? What is the function of male nipples, the appendix, facial hair? Why has evolution selected humans to be so helpless for such a long time after birth? How can we understand the mechanisms of thought, personality, and memory without invoking qualitative descriptions? Why is it so difficult to define the experience of pain, explain addiction, or predict violent behavior?

Some of the answers come from looking at the questions from a different frame of reference. Individual mutations are usually harmful or fatal to the individual, but the occasional adaptive mutation helps insure the survival of the species. The application of the uncertainty principle to genetics implies we cannot know the significance of genetic differences by examining individuals; we must look at the whole group of individuals who are interrelating. In psychology, the uncertainty principle is exemplified by the Baxter effect: when students teaching rats to run a maze are told their rats are smart, the rats learn faster than when the students are told the same rats are stupid.

Biology's analogy to relativity theory is the concept of ecology. Individuals and their environment are inseparable; neither makes sense without understanding the other. On the quantum mechanical scale, biology offers the concept of symbiosis. Beans and nitrogen-fixing bacteria depend on each other for nutrients, neither would survive without the other. The nudibranch and the medusa take turns ingesting each other; both are parasitic, both are prey.(5)

Perhaps the most amazing and ubiquitous symbiosis occurs inside almost every cell in our bodies: the mitochondria. These structures contain their own DNA, can reproduce independently, and live as intracellular parasites. Their genetic material is carefully passed from mother to child because the mitochondria perform one useful biochemical trick for us: they allow us to utilize oxygen.

Green plants have a similar relationship with chloroplasts; their useful trick is to convert light into food (E=mc²?). The biological food chain consists of humans (who depend on their bacteria for vitamins and their mitochondria for energy) ingesting plants (which utilize the carbon dioxide we exhale and the light from the sun to produce carbohydrates) which recycle the water and minerals created by the death of stars.

God's Body
We are given God's body
the universe--to live in--
not as parasites,
but as blood cells,
stewards of life,
custodians
moving from breath to dance.
We are given God's body,
a sacrificial sun
enveloped in energy
radiating little in return,
storing seeds for winter.
We are given God's body
complete with clitoris,
male nipples, pubic hair--
designed for pleasure.
Why are we displeased,
given gracious gifts?
We are given God's body--
mother, lover, friend and planet
to live in and live with:
self-healing when nourished,
growing stronger when loved.
 


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Watching television, you'd think we lived at bay, in total jeopardy, surrounded on all sides by human-seeking germs, shielded against infection and death only by a chemical technology that enables us to keep killing them off. We are instructed to spray disinfectants everywhere . . . We apply potent antibiotics to minor scratches and seal them with plastic. Plastic is the new protector; we wrap the already plastic tumblers of hotels in more plastic, and seal the toilet seats like state secrets after irradiating them with ultraviolet light. We live in a world where the microbes are always trying to get at us, to tear us cell from cell, and we only stay alive through diligence and fear. (6)

The sciences are often divided into "hard" and "soft" sciences. Physics and chemistry are considered "hard"  sciences. Psychology, economics, sociology, and anthropology are examples of "soft"  sciences. Biology falls in the middle of the spectrum. I think the phallic implications of the terminology are not accidental. The "soft"  sciences have less status, less precision, and attract more females. Although medicine is considered a "soft"  science, its metaphors conjure up masculine heroic struggles more often than symbiotic peaceful coexistence.

Until the twentieth century, there was little application of science to medicine. The impact of the germ theory lead to major breakthroughs in antisepsis, antibiotics and immunizations. Such powerful achievements have led modern physicians to view the pre-scientific days as primitive, ineffective, even horrific. They have also created a bias against areas of medicine that cannot be easily quantified.

We are survivors of the Cold War against Communism, but not yet against the Germs. Yet some germs are good for us. They make vitamins, help maintain the proper pH on mucosal surfaces, and produce antibiotics that we use to fight infections. Many of our infectious diseases are not so damaging in themselves as in the body's response to them. Streptococcal pharyngitis, for example, rarely causes any permanent damage to infected individuals, but the antibodies we produce against the streptococcal M proteins may attack our own heart valves (rheumatic fever). Still we persist in viewing disease in a linear, military fashion: pathogenic micro-organism invades susceptible host producing immune response resulting in either victory (recovery) or defeat (death).

The training of physicians is a socialization process, one which teaches by example and role model. When medicine is seen as mechanistic, physicians become mechanics, not healers. Mechanical work is manly, logical, clear cut. This may explain the preponderance of men in the field of orthopedic surgery.

Iron Men
work without sleep
show no fear
shoulder all
grint their teeth
protect the little lady
shaking inside
not death, but shame
jousts toward him
he bleeds out
clutching his visor
sissy, weakling, coward
stand up like a man!
show 'em what you're made of
iron in muscle and heart
why doesn't it rust?
this soft, saltwater iron
flexible and yielding
durable myoglobin
afraid of a woman
sure she casts spells
has a magnet for your iron rod
you spin around her like a compass
her roulette wheel, your money
wanting that woman
who always comforts
always lies in waiting
believing in you
encouraging, guiding
leading from behind
mystified
that she, weaker, less logical
can create new life from her body
new flesh from blood and water
holding on without hardware
food flooding her breasts
no wonder knights fear damsels
dragons have fierce weapons but few
the maiden's honeyed lips
latch as fleetingly as granite

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The application of reductionist and interventionist biases to medicine has resulted in a catalogue of horrors. Some colorful examples follow.

• 1. At the beginning of the 20th century addiction to morphine was recognized as a serious medical problem; the solution was a new synthetic drug which cured morphine addiction without causing withdrawal. It was called heroin.
• 2. At the same time Sir William Arbuthnot Lane had found the cure for diseases caused by bacterial toxins. Since the colon harbored billions of bacteria, he routinely performed total colectomies.(8)
• 3. The 1940 Nobel Prize in Medicine was awarded to the surgeon who introduced a new treatment for schizophrenia: the pre-frontal lobotomy.(9)
• 4. X-ray treatments for enlarged thymus glands in children caused cancer.
• 5. DES prevented miscarriages but caused genital cancers in the offspring.
• 6. Oxygen rescued premature infants from death due to hyaline membrane disease, but caused blindness due to retrolental fibroplasia.
• 7. Phenformen was an orally effective treatment for diabetes that killed by causing lactic acidosis.
• 8. Atromid-S was an early cholesterol-lowering agent which increased the risk of heart attack.
• 9. Flecainide suppressed premature ventricular beats, but caused sudden death.
• 10. Even lowly aspirin, now touted as a preventive for heart attacks and strokes, can cause fatal Reye's syndrome in children.

Medical science has little theoretical basis, and very few testable hypotheses. Most innovations are the result of hunch, trial and error, pure empiricism. Too often they are accepted by the medical community before they are proven.(10) Even purely observational studies in medicine have had their dark side: the best documentation of the natural history of syphilis was a longitudinal study of infected black men who were never offered treatment even after it became available.(11) Much of our understanding of the response of humans to extreme temperatures and pressures is based on experimentation done on inmates in Nazi concentration camps. Our detailed knowledge of hepatitis B resulted from observations in a repository for retarded children.(12) We may soon read about the spread of AIDS in prison populations denied access to condoms. What is missing from these studies is not scientific rigor, but human compassion.

Before scientific reductionism was applied to medicine, women had a much greater role in health care. Most deliveries were performed by midwives, and most nursing was done by female relatives of the afflicted. By framing medicine as a macho, military struggle, we have minimized the nurturing, compassionate, caring skills traditionally performed by women.

Those who wish to learn the role of healer seek an integrated approach: they are concerned with context, relationship, feelings and other unscientific variables. Healing is not mechanistic; it requires a loving relationship. Its goal is not the vanquishing of disease, but health. As the charter of the World Health Organization nobly states: "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

Unless we have a carefully constructed framework of ethics, applying science to medicine can be disastrous.

"The body of technical science burdens and threatens us because we are trying to employ the body without the spirit; we are trying to buy the corpse of science. We are hagridden by the power of nature which we should command, because we think its command needs less devotion and understanding than its discovery. . . Massacre is prevented by the scientist's ethic, and the poet's, and every creator's: that the end for which we work exists and is judged only by the means which we use to reach it. This is the human sum of the values of science."(13)

Owed to Keats
(who forsook medicine for poetry)
Fair son of Apollo, encircled by muses,
you fought not plagues with potions
but indolence with verses.
You did not lift up the wasting body
yet sought to soothe the soul with sonnets.
You knew the helplessness of the death-bed
"where men sit and hear each other groan,"
the futile medicines of old:
wolf's-bane, nightshade and yew,
as like to kill as heal a melancholy soul.
To choose the pen and ink instead a scalpel
yields solitude only in the crafting,
not in sharing sword-like songs
with "kindred spirits" so inclined
to "nature's observatory."
No studied herbs, you selected verbs
to slay the phantoms of the night
which kept the longing lovers from their clasp,
taunted with their unheard melodies:
yearning verses shortened by untimely death.
I call not upon your Olympian hordes for help,
seek not Homer, but ethambutol and isoniazid
to soothe your brother's pallid cough and rusty phlegm,
your own consumption weakening your hand
'til neither remedy nor line of poetry could write.
What wondrous words were wasted?
Your lines still earn a sylvan history.
You were a friend who spoke the truth,
taught us beauty, fleeting like a race,
outlived a man who marked its place.


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Bewilderment is kept hidden in the darkest closets of all our institutions of higher learning, repressed whenever it seems to be emerging into public view, sometimes glimpsed staring from attic windows like a mad cousin of learning. It is the family secret of twentieth-century science, and of twentieth-century arts and letters as well . . . The more we learn, the more we are--or ought to be--dumbfounded.(15)

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The heretical truth is that medicine, like science, is inherently uncertain. Very few patients are considerate enough to read the medical textbooks and present a "classic" picture of one particular disease. (Those few who do are usually hypochondriacs or drug-seekers). Physicians gather a somewhat haphazard history of imperfectly remembered symptoms and extraneous details:

"When did you start having the chest pains, Mrs. Jones?"

"Doc, it all started when I went over to Beulah's for our weekly bridge club meeting. We had just eaten our potluck dinner and everyone was praising my meatloaf when we started playing cards. My partner and I were doing well, in fact we had just bid and made six no trump doubled when I had this kind of indigestion feeling in my lower chest. The heck of it was, I had another great hand right after the last one and wanted to bid another small slam, but I had to excuse myself to go to the bathroom . . . "

The specter of uncertainty creates a conspiracy of both doctor and patient to pretend that diagnosis is simple, uncomplicated and unambiguous. The physician would rather not have to take the time to review all the possible diagnoses in the differential and then rank them in true order of probability. He will mention a few that he can remember and diagnose the one that he is most familiar with or can treat most confidently. The patient doesn't want to hear a long-winded lecture about all the possibilities, he or she just wants to be able to tell relatives or friends what is wrong and what treatment is recommended.

Why is uncertainty so frightening for both patients and doctors? It destroys their sense of being in control. Patients usually fear the worst. When they don't completely ignore their symptoms, they automatically assume they have cancer, AIDS, insanity or whatever disease just killed their favorite television character.

When patients go to the doctor with a problem that they don't understand, which makes them feel sick and which might interfere with their continued enjoyment of life, they feel scared and vulnerable. Besides, the doctor rarely tells them anything good; at best he tells them to take better care of themselves. At worst he may tell them to make sure their wills are up to date.

Doctors fear uncertainty because it reminds them of their vulnerability. When a physician is mistaken, it's more than inconvenient--it may provoke a lawsuit, a lost patient, a loss of license and livelihood, or at least a loss of self-confidence. Honest physicians will admit that they don't always know everything they could or should know about their patients and their diseases. That's why people get asked fourteen times about medication allergies when they get admitted to the hospital. That's why the surgeon asks three times whether it's the right knee or the left knee that hurts before he operates.

Uncertainty also reminds doctors of their days as medical students, being "pimped" by the house staff and attendings about minutiae. It reminds them of their frightening experiences as green interns, having to make spur of the moment decisions that could cost a life. It reminds them of the feeling that they alone somehow fooled their instructors into believing they really were competent, when doubts and fears still lurked inside themselves. Medical house officers who take responsibility for their mistakes may make adaptive changes in their behavior, whereas those who blame others or deny them learn to cover up.(16)

Medicine is wistfully described by older physicians as an art, but is usually taught to medical students as a science. It takes a lot of contrary experience for physicians to realize they are not physicists. Physicians who strive to derive "laws" or protocols that will ensure success in treating patients are usually foiled in their efforts. Human beings are even less predictable than subatomic particles.

Perhaps those old-timers nearing retirement from medicine have learned something important about medicine as an art. Art requires personal commitment, requires effective communication, requires passion, requires courage. An artful physician cares for his patients because he cares about his patients. He is personally and passionately committed to doing his best job for them, not out of fear of lawsuits, but because he can't imagine behaving any other way. He is concerned more about what is right for the patient than what is convenient. He is willing to draw upon his own life experience to empathize with his patients' suffering. He is willing to face uncertainty because it comes with the territory, not because he prefers ambiguity. He is practicing a pragmatic art, one that must be grounded in reality to achieve good results. Wishful thinking rarely removes a hot appendix. Knowing that some right lower quadrant abdominal pain may not be appendicitis will not dissuade him from operating if he has determined that appendicitis is likely enough. He is willing to give his patients his best shot, even at the risk of being wrong, for to not try at all is a far greater failing.

We live in an uncertain world. Our challenge is to make the most of our talents, time and relationships. If we fail out of fear, we deserve pity. If we fail out of arrogant over-simplification, we deserve contempt. If we fail because of our indifference, we deserve punishment. If we fail in spite of our best efforts, we deserve encouragement.

Why do perfectly intelligent college students decide to enter the career of medicine? The question is a cliche of medical school interviewers. The answer is usually phrased in altruistic terms. Helping the sick and alleviating suffering are acceptable reasons to pursue medical training. I suspect that achieving prestige, power, job security, respect, and usefulness also motivates medical students. There are often intensely personal reasons: a close relative who suffers from a painful disease or who died unexpectedly may spur on the white knight instincts inside a taciturn applicant. I have known some students who greatly benefitted from modern medicine; they seek to repay the debt or return the favor.

Although the content of medical education is continually evolving, a large part of becoming a physician will always be learning to act like one. Traditionally, this was accomplished through a rite of passage, an initiation into medicine, truly a trial by fire. Long hours, sporadic sleep, poor food, lack of exercise and little emotional support typify the modern ordeal. During their four years in medical school, 72% of all students will be the victims of physical or emotional abuse dished out by superiors.(17) Students who do not match their instructors' stereotypes have more difficulty. Men who are less masculine than the norm or women who are less feminine are much more likely to be abused.

The reason physicians need to be compulsive about their patients' diagnoses and treatments is an implicit fear: screw up and get sued. Under the circumstances, it's no surprise that physicians don't admit their mistakes. Occasionally, a truly revered physician will tell an anecdote about a case he blew (usually in the distant past). Clinical conferences usually reinforce anxiety and guilt more than inspire honest appraisals of our behavior. Thus a strong message to future physicians is delivered: know your facts, be responsible for your patients, and it's every man for himself. There is no room for weakness, no sympathy for inadequacy, no admission of fear; you must act like us to be accepted.

Abuse

Rather than select future doctors on the basis of their science and math scores, medical schools would serve patients better if they could evaluate students' potential for empathy, their communication skills, their integrity, and their capacity for love. What medical students truly need in their training is permission to fail, opportunity for mutual criticism and feedback, and an emphasis on honesty to themselves as well as to their patients. They require emotional support from their peers and teachers as well as their families. Recognition of personal needs and their impact on interactions with patients should be explored. Rather than expecting gratitude or adulation, students should develop internal incentives. They can emulate physicians who have a life outside of medicine, who have time for a family. Lastly, student physicians need time to learn the terrain, experience life, become more complete human beings themselves before their advice to others will carry any weight.

The results of enacting such reforms in medical education could be dramatic. Imagine a generation of physicians who were less competitive and more cooperative with each other. Try to envision physicians who had more emotional energy for their patients and families. Imagine a system that treated impaired physicians compassionately, one that truly rehabilitated. Imagine fewer chemically or emotionally impaired physicians, fewer suicides. Imagine learning to become a healer in an educational system that practiced what it preached.

Batter Up
 
I'm a doctor
delayer of death
but not its foe
every day people
show their wounds
share their germs
reveal their worries
unload their pain
in one of my little rooms
I'm a counsellor
what to eat & what to drink
when to rest & when to work
what to take & what to stop
how to get pregnant or not to,
what crutches to use
when the body disobeys
I'm a family doc
a catcher who can
pick a curve ball out of the dirt
withstand the pounding of the hard stuff
and still finesse the hitter with a changeup.
I have a trained ear
not just for music
but for nuance:
the strained plea for assurance
in the new mother's laundry list
of concerns about her newborn;
the despair of the old woman
married to a demented tyrant
who gave her life savings to charity;
the false bravado of the single young man
who wants an AIDS test "just to be sure"
There's plenty of pain to go around
we all hide and feed our own
and surprising as it seems
the burdens are lighter when shared
an honest tear or encouraging hug
can strengthen more than spring training
does an aging ball player.


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"Physician, n. One upon whom we set our hopes when ill and our dogs when well."(18)

Patients are bombarded with information about their health. There are medical discussions in popular magazines, newspaper columns and television talk shows. Unfortunately, much of this information is sensational, titillating, or incorrect. Crackpots are more likely to get air time than careful scientists because the crackpots are usually more entertaining. Since most patients have little background in critical analysis they absorb all information as if the credibility of the source were irrelevant. Patients will test their doctors' answers against what they've heard or read. I remember a patient waving a tabloid paper in my face demanding to know why he wasn't taking this new miracle drug to control his cholesterol. It turned out he had been on it for more than a year. He'd never noticed that the generic name on his bottle was the same as the miracle drug in the article.

Physicians can learn humility from realizing their place in the patient's hierarchy of authoritative sources of information. Television is number one: if you can see it and hear it at the same time it must be doubly true. (That's why drug companies now target ads for prescription drugs directly to the patient.) Next in importance are the patients' friends and relatives: they always had something just like the patient has and know exactly what to do for it. Third in line are casual acquaintances: if the guy down the street died from that operation or got sick from that drug, they're not going to risk it. Lastly, there's the physician: his opinion costs, and it's likely to be garbled with jargon and adorned with weasel words. Any time the doctor is right, he's just doing what he's paid for. Whenever he was wrong or failed to adequately predict the future, it's a ripoff.

Patients know that even when they might want a physician's opinion, the physician is usually unavailable. If they call the office, the physician rarely calls them back. If they insist on talking to the doctor, it's golf day or the doctor is in surgery. If it's a weekend or after hours, and the doctor actually takes the call, he'll probably be annoyed and condescending. Patients don't understand why their doctor can't be available 24 hours a day, 7 days a week, 365.25 days a year. After all, their problem is important to them, why shouldn't it be to him? Besides, doctors have it made, driving their Mercedes from mansion to yacht. Okay, so I drive a Toyota and have a sailboard; there's a little truth in the stereotypes.

I think a lot of the tension between doctor and patient boils down to fear: fear of criticism, fear of abandonment, fear of suffering, fear of death. Doctors evaluate their patients' problems better when they see beyond the content of the patient's speech to the motivation behind it. What the patient is often asking for is a competent and compassionate partner to see him through his struggle.

Physicians have their own barriers to partnership with patients. Even when patients take responsibility for their own health, it can be difficult to share decision-making. The doctor's ego is massaged more by making brilliant diagnoses and curing the patient single-handedly than by a collaboration with the patient. Also it's more expedient to placate an anxious patient with platitudes than to discuss honestly the risks and benefits of all the alternatives. Most doctors have had experiences of giving their best effort to help a patient only to be ignored, or even denigrated. Physicians read medical journal articles which confirm that fewer than half of their patients will do what's recommended. No wonder they get cynical, nihilistic, depressed. What's more, if they invest their time and emotion on the patient's behalf, there's a good chance of being hurt deeply sooner or later. Is it realistic to expect a physician seeing thirty patients a day to be intimately involved with each of them? What good physicians do is budget their efforts; the most needy patients should receive more time and effort. The physician must be able to minimize distractions and to tune in to each patient for the time they are together as if nothing else mattered.

The key to a productive partnership between patient and physician is the realization that both are on the same side. Both want the patient to do well; both have to be willing to let down their guard a bit and trust each other. The patient is the only one who is an expert on how and what he feels. The physician may have much greater experience making sense out of the symptoms and signs. If both are honest, it is much more likely that an accurate diagnosis and treatment plan will be reached.

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The deconstructionists want to become the ultimate scientists of poetry, looking at every word in a line with essentially the reductionist attitude of particle physicists in the presence of atoms, but still unaware of the uncertainty principle that governs any good poem: not only can the observer change the thing observed, he can even destroy it.(19)

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Of the fine arts, music has had the longest association with medicine. David became an aide to King Saul because his harp playing helped to soothe the king's fits of rage.(21) Music is still utilized for its therapeutic benefits. Examples include patients being sutured in the emergency room, undergoing MRI scans,(22) suffering pain from cancer,(23) coping with degenerative diseases,(24) struggling with Parkinson's disease(25) and recovering in the coronary care unit.(26)

The analogies between healing and music are striking. The parallels between rapport (doctor-patient relationship) and ensemble are an example. Just as there is risk in putting sincere emotion into a musical performance, there is risk in putting one's honest emotion into a "therapeutic" alliance. The vulnerability in each case is necessary for the recipient to get the full message. In each situation, the risk of rejection, criticism, and misinterpretation weigh against the nebulous benefits of reaching out to a previously unknown person. The satisfaction of receiving feedback from someone who has truly appreciated your gift vastly transcends the sterile pleasure of performing competently, professionally, or even flawlessly.

Music can inspire us to transcend our usual attitudes and approaches to people and events around us. Lewis Thomas describes such an experience:

" . . . what I heard, especially in the final movement, was an open acknowledgement of death and at the same time a quiet celebration of the tranquility connected to the process. I took this music as a metaphor for reassurance, confirming my own strong hunch that the dying of every living creature, the most natural of all experiences, has to be a peaceful experience."(27)

Medicine, like art, is replete with metaphors. Many descriptions of physiological processes and diseases require translation into the patient's everyday language. Understanding the patient's background, educational level and job experiences helps the physician fit the right image to the task at hand. Imagery and symbolic description provide a richer, deeper view of the processes of life, a view that is some ways is more true than simply describing them in technical terms. The patient is more likely to comply with therapy if he has a vivid view of the consequences. Since most of my patients own cars, I often use automobile metaphors with them. A cataract is like a dirty windshield. Preventive medicine is like buying new tires before they blow out or getting an oil change before the engine burns up. I point out that it's harder to find replacement parts for people than for cars. Thus metaphor can be mnemonic.

If a physician is to be an artist, each patient encounter is greeted as an opportunity to test his skill and creativity. Patients respond positively when the communication is at their level, using their style of humor, and relevant to their problems. Besides being a more effective technique for delivering health care, an artistic approach to medicine makes it more fun for all participants. Just as a musician develops awe and respect for the accomplishments of great composers, a physician can be inspired by the amazing intricacy and capacity for self-regulation of the human body. Just as a dancer or a mime communicates through movement, an artistic physician can communicate with gesture and touch. Just as a great actor enthralls an audience, a great physician can motivate a patient with a well-aimed, sincere performance. Artful medicine helps us proceed through our life and work with a sense of wonder, an appreciation for humor, an eye for beauty and a sense of grace.