Progress in Medicine
As the history of medicine has evolved, a number of trends and prevailing opinions have swept the profession. One of the most subtle, and yet most revealing results of these sweeping trends manifests itself by altering the tone in medical conversations and dialogues, often available to the non-medical person in the form of texts and literature. A relatively current example appears in the form of Perri Klass’ A Not Entirely Benign Procedure, a text dedicated to the experiences of the author at Harvard Medical School. Published in 1987, Klass’ work offers an interesting, if not shocking comparison to Philippe Pinel’s “The Clinical Training of Doctors,” an article published in 1783. It seems that, despite the obvious advancements and progress in medical technology and general care, the modern Klass presents less certainty about the profession and its abilities than does the eighteenth century article. In Pinel’s article, however, a distinct tone of holistic healing pervades the proposed training of physicians—the lack of which Klass bemoans in her work. The contrast between the two works affords the reader a view into two parallel transitions in medicine: the decline of certainty and the decline of holistic care.
One of the most shocking aspects of Pinel’s article involves the specificity in patient setting and observation he demands. From precise measurements of the weather to room orientations, Pinel seems to imply that precision in observation and care-giving will lead to precise diagnoses and eventual cures: “It is obvious that medical observations can be precise and conclusive only if the evidence is reduced to the smallest possible number of facts and to the plainest data.” The outline for the training of physicians Pinel proposes attempts to create an environment that allows the kind of precision that will lead to conclusive outcomes in patient care. Pinel’s demands range from the sensible to the seemingly outrageous. His proposal to closely scrutinize the diets of patients, as well as to experiment with these diets, seems to coincide with modern beliefs and practices. Indeed, just as Pinel recommends, one of the first and fundamental questions asked by any physician or health care provider involves an investigation into previous food intake. Most of his section entitled Questions to ask upon admitting a patient conforms with modern practice. The more extreme requests and propositions, however, offer a more penetrating insight into his and his time’s beliefs concerning the potential of medicine.
Pinel requires that his teaching hospital be equipped with a battery of meteorological instruments in order to enhance the level of precision in determining the potential influences on patients. To function accurately and properly, the physician must account for all possible influences on the health and condition of the patient: “Notes on celestial observations, meteors, and the phases of the moon should complement the daily recordings from these [meteorological] instruments.” Oddly, this level of observation requires a near impossible exertion of effort on the part of the physician, and it would be a wonder if the patient did not succumb to his illness by the time these initial observations were made. The implications of Pinel’s suggestions include the assumption that a cure can be found, and precise scientific scrutiny will inevitably reveal its location.
As an interesting aside, Pinel wrote well before the time of scientists like Heisenberg (circa 1900), who helped elucidate the fundamental impossibility of knowing all the possible outcomes of a situation by merely understanding the initial conditions of that situation—the premise of modern Chaos Theory. Heisenberg’s Uncertainty Principle was a watershed moment in the general paradigm of science in that it posited a limit on the accuracy of observation. Knowledge of the position of a particle came at the expense of knowledge of its velocity, and knowledge of velocity, at the expense of position. One of the hallmarks of modern science includes its attempts to cope with the realities and implications of unconquerable fundamental uncertainties. In some small way, Klass conveys this general scientific uncertainty from a personal perspective, which in turn reveals its presence in the entirety of medicine.
In her segment entitled Curing, Klass depicts the presence of uncertainty in the modern medical profession. She does not deny that the expectation of cure still represents the model of the physician, but she does mention that this needs to change. Her reasoning is simple: “It’s frustrating to want to cure, to carry with you the expectation that somehow you should be able to cure, and then not be able to cure.” She intensifies her point, and provides evidence for the fact that this is not merely her own personal opinion, but rather more far-reaching in medicine, when she describes what she is told when learning about a treatable, curable illness: “And this one really makes you feel like a doctor.” The true sense of physician only comes with cure, but Klass, and many other physicians come to realize that there exists much they cannot cure. Because of this, Klass argues for emphasis on such things as preventative medicine and “life-style issues” —an argument that remarkably resembles the holistic manner of care presented in Pinel’s article.
As the best method to teach medicine, Pinel advocates the training of the physician as a comforter, as well as a healer. He remarks on a number of psychological remedies which result in the increased comfort of the patient. His argument stems from the belief that despair leads patients to an early demise, and that positive thought aids in recovery and cure. Comfort and activity, resulting in mental well-being are indispensable tools of the physician in his attempt to alleviate illness. Klass laments the fact that modern physicians, in the face of failing diagnosis or treatment, request more tests and more adventurous invasive procedures, rather than adjusting to a role of comforter and caretaker. Pinel advocates only the simplest medications and interventions in an attempt to cure, and notes that most often, as in the example of Hippocrates, diet is the source of cure. Pinel does not waiver from his pursuit of cure, but his methods incorporate a more holistic and comforting manner in which to seek it—more holistic and comforting than the manner in which Klass observes its search in modern medicine.
An odd, but unmistakable parallel begins to emerge from a comparison of these two works by Klass and Pinel. While medicine supposedly advances as history progresses, certain vital aspects are noticeably missing. Advances have led to some understanding, as evidenced by Klass, that the search for cure should not serve as the model for the role of the physician. The implications of this understanding, however, do not manifest themselves in modern medicine, where a failure to cure represents a failure of medicine, and a failure on the part of the physician. Without the benefits of technology and, more importantly, without the benefits of the radically influential ideas of Heisenberg and others, Pinel hopes and writes assuming that every cure can be found through careful scrutiny and observation. He also writes knowing that physicians in his day do not successfully cure all patients. It seems that from this practical knowledge, Pinel derives his argument for a holistic approach to medicine: “train their judgment rather than their memory and inspire them with that noble enthusiasm for the healing art that masters all difficulties.” Technology has afforded modern medicine with the illusion that more tests and more procedures can cure the patient—an illusion not too far removed from that of Pinel. Unfortunately, in the case of modern medicine, the need for more holistic methods of care-giving, as illustrated in the writings of Klass, remains unsatisfied, despite evidence indicating that even the most precise observation and care cannot solve all problems. While progress in medicine has left unparalleled technology and knowledge at the disposal of the modern physician, it has left behind a holistic and comforting manner of care that would greatly enrich the role of the physician and medicine.