Here’s the educational strategy in American medical school. Of the four years span of medical school, the first two years address pre-clinical learning, classroom work covering a huge set of facts and understandings of the basics underpinning the modern understanding of the theory and practice of medicine. The last two years are spent in the clinic, where true learning commences. Medicine is only what is undertaken in the care of the patient.
p style=”text-align:justify;”>The first two clinical years are opposites, in many ways. The first year presents the Form of the Human Body in Health. Few educators consider that study in the first year has specialized in this broad topic. But it is a classical instruction of Form – of ideals.
p style=”text-align:justify;”>The Well Human is a Form – it is timeless. Individual persons resemble the Human Form. The model of the well human body is a Form, in the traditional philosophical sense. It is timeless. It is made up of elements, such as organs, that exist purposefully, to fulfill a teleological mission. As the sum of all of the elements go about acting for their temperate and balanced purpose, the combined human whole is in a state of wellness. To understand the Human Form is the purpose of the first year of medical school.
The second year represents the study of the various things that disturb the human form. Deviations from the ideal Human Form comprise illness. The vicissitudes of such deviations, over time, is called the study of disease. Each disease can be collected into nominal sets pertaining to diseases of the different organ systems. They can be codified into classes, such as genetic, infectious, vascular, metabolic, endocrinological, autoimmune, neoplastic and toxic or traumatic – due to external agents. But unlike the reality inherent in the Form of the Human Body in Health, disease is not a self-sufficient entity. It is a derangement of the human Form. Illness is the void left when wellness is perturbed. This is critically important to understand. Pathology is nothing like physiology, disease is not like health. It is the effect of an unseen process that leads to disease arising in the well human.
The study and analysis of the common and unique expression of disease and illness by the Human Form comprises the second year of study in medical school. Upon attaining general understandings of wellness and disease, the student is ready to begin a process of of a lifetime of learning through observation and inquiry in the care of individual patients. This is the realm of Francis Peabody’s The Care of The Patient. It is a never-ending education for the practitioner.
HOW ONE CONFRONTS ILLNESS
In every set of symptoms and signs that infers the existence of illness, one seeks the cause of the illness. This process is tightly analogous to the study of motion in physics.
Physics, the study of motion of objects, understand that movement is determined by the total of forces acting upon an object. An object can only move in the direction to which it is determined. In physics, this is referred to as the principle of least action. A certain equation, the Lagrangian, permits calculation of the numerical parameters of motion, such as position over time, given the elements of the object.
p style=”text-align:justify;”>Perturbations in human wellness which are diseases effect certain effects upon the human form. People exhibit a certain body temperature; disease can perturb this temperature in a certain common way. The physician examines, observes and measures the abnormalities of the ill person, and asks – what is the simplest external perturbing force that can cause these symptoms and signs in this particular patient? How can I find the process that most effectively and economically produces these perturbations? And how can I interrupt the perturbation to restore wellness?
My patient had recently started taking a new medication which I prescribed. Shortly after the first dose, he had fever, chills, malaise, nausea, vomiting, and a headache. He went to the emergency room. He had a white count, no diarrhea, no pain, and an uncommon gram-negative bacterium in his urine. What was the cause of his symptom set?
When doctors talk to one another, they often prepare the cluster of symptoms, signs and findings into a narrative. Narrative skills are endlessly practiced in medicine – or used to be. The secret of medicine is that it is an oral culture. Doctors convey information to each other verbally, and preferably with eye contact. No written, digital or other means is as information-rich in communication as the verbal discussion.
The ER doctor did not call me for advice. Forty years ago, this would have been an inexcusable insult, as well as a foolish error by the ER physician. Nowadays, it is entirely the standard of practice. Nobody calls each other any more to discuss a patient. This is more dangerous than any other risks in the care of a patient.
p style=”text-align:justify;”>The ER doctor stopped my medication, as it was the most recent change in his healthcare regimen. The ER also saw that my patient apparently had a urinary tract infection, and gave him antibiotics. They sent him on his way, with one less medication and one new medication. This was technically correct, competent care. It is the best one can hope for nowadays.
Do not misunderstand. My patient got good care. He simply did not get the best care possible. That distinction is only a matter of private pride, not professional action.
What was missing from the ER visit was a diligent exploration of a course of medical thought to understand the cause of his illness. Illnesses have a material cause. They are not visited by ill humors or curses or mystical factors. If they perturb the form of health, they have a material process which they represent. Experience and training offer the ability to recognize the different ways of the deviations from health. A patient understanding of my patient’s distress pointed entirely towards an infection of some sort, and the only infection appearing was the urinary tract infection. One of the memorized saws for unexplained fever is the five W’s – wind, water, wound, women (GU) and walking (meaning venous thrombosis.) All his symptoms spoke of an infection. This would be water. It is good that they gave him an antibiotic. But it was done reflexively.
Hubris is being stamped out of medicine. But what is called “hubris” is daring to make a decision, have an opinion, to think, to go out on a limb. Such behavior invites blame if one is wrong. Once, deference was granted to experts who took a mistaken grasp on a situation, especially under the pressure of time. Now, everyone is a Monday-Morning Quarterback. There is heavy pressure not to make any decisions for which one can be blamed. Why bother?
The most efficient understanding of the patient’s illness suggested a urinary tract infection, namely, a mild outpatient pyelonephritis, or kidney infection. More serious pyelonephritides require hospitalization; his did not. He had systemic findings, which are not common in simple cystitis. But without a clear and discrete diagnosis that fully answered the question of what caused the patient’s symptoms, he left the emergency room knowing nothing.
He came to see me a few days later. He retold the story and I examined him. The drug which was recently started was a complete red herring, and he needed to take that drug, so he re-started it without adverse effect. The treatment for outpatient pyelonephritis was abbreviated; I extended the treatment to the proper length of time.
All too often now, I see reflexive medicine, where a patient presents with symptoms, and the treatment is reached for without any consideration of whether the diagnosis would explain the findings and symptoms. Legally, as long as the patient is treated for something that COULD have caused the findings, there is no failure to treat. It need not be right or wrong treatment, good or bad treatment. What matters is that something is done that would cover something that might look like this.
Medicine has no responsibility of “getting it right.” It now required only to not get it wrong too ridiculously. What happens to the patient is, however, not central to the discussion.
I had the surprise of receiving a “new patient.” He was convalescing with his son for a few months. He came to me in atrial fibrillation, with a reported ejection fraction of 6%. (Unlikely. He seemed at least 10-15%) I had to babysit him after he was seen in his home town, and was due to see a cardiologist back at home in 2-3 months.
I delighted in the challenge, really. I tuned him in using modern technology – the digital scale. I followed his creatinine and BNP, that gave me useful feedback; but it was a matter of finding out if he was too wet, by dyspnea, or too dry, by exam. Thus, we found his dry weight. It was fun.
I called the cardiologist he was to meet; he hadn’t seen yet. I signed out my patient to him. The cardiologist offered all the excitement of receiving a bag of wet laundry. He sounded burned out. I felt a little sad for him. This guy was tuned up and had a bow on him. In the old days, cardiologists would really appreciate a tuned up patient coming in. The cardiologist was just too tired to talk. I was kinda sad. This patient was a matter of personal pride for me. But nowadays, one doesn’t show off one’s best work to any compliments.
I offered critically valuable information for keeping my patient well and out of the hospital. I felt like I was giving an order at the drive-up.
MEDICINE AND THE TAO
The Tao is merely the observation that the patient has been detoured from health into illness. Treatment is merely what restores the patient to a better path, ideally to wellness, in a way that satisfies their wishes. That’s all the Tao of Medicine is; it’s really simple.
The medical specialty that most closely mirrors the Tao is obstetrics. Childbirth is a force of nature which progresses, in which the woman is centrally involved, but who has little control over the process. It is more like a tsunami than any human enterprise. The goal is to ride through it most effectively and properly.
Some women surf cleanly through labor and delivery; and some fall and tumble, and tumble, and tumble. Some never can get aright through it all. Some will struggle and get ahead of it again, with much effort. In surfing, you are either Off The Board, or On The Board. There is no in-between, and Off The Board sucks. A rare few ride the wave with exhilaration, and experience it in a wonderful fashion; very few. And it it not a mark of character whether one woman rides through it clean, and another tumbles and eats beach. It’s a force of nature.
The role of the Obstetrician is (a) get everyone through it alive, and (b) try to right what has gone wrong. No obstetrician actually controls anything. They don’t do a delivery, in the way somebody does an operation. They participate in it.
Obstetrics, and to some degree many surgeries, and resuscitations, are all deep in the Tao of medicine. I have done only resuscitations, and have brought a few people around. Sometimes, you bring people back, from there – they were away for a while. It’s not that they come back to life, but rather their life returns. It’s impossible to explain clearly. I had one guy open his eyes, look at me and say “thank you.” That means a lot to me.
And the knowledge inherent in the Tao of Medicine is rapidly being abandoned. One more generation; it will be as lost as any ancient art that was forgotten in the Dark Ages. Nowadays, nobody needs to know how a sick person looks, or a well person looks. All that’s needed is merely to look up a symptom and give a medication that will alleviate it. Medicine has bet on a dangerous myth – that is, impersonal algorithms can be constructed which lead invariably from every conceivable type of symptom to its relief. Without the presence of experience and insight, the best people have to look forward to is mediocrity, at best; or sincere regrets from the medical organization, at worst.
I’m sure that in every collapse of civilizations, up until the very end when the “lights go off,” the participants don’t sense dread. They probably feel proud about the Fine New Way of Things that they are following. That we are following, I expect.
This bad path has bee aggressively pursued for twenty years, pursuing the myth that medicine will be better if it only resembles the sale of retail products. It is the myth that Wal-Mart medicine is the best medicine imaginable. It certainly is the medicine that will be here within three years.
If it’s obvious to patients that medicine’s going in the wrong direction, and obvious to doctors that medicine’s going in the wrong direction, well then – who’s made the decision for us to go this way?
Twenty years ago, when the energy began to gather to improve medicine, it was to STOP this sort of growing pattern, not to ACCELERATE it. Qui bono? Who’s making the loot off this maneuver?