The Yale Journal for Humanities in Medicine
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The Accurate Eye,
The Truthful Ear
(continued)
Howard Spiro, M.D.
howard.spiro@yale.edu
Clinical reputations used to be built on coming to correct or at least helpful conclusions on insufficient data. But now there is a new-found insistence on certainty. During some years at Yale Law School, at the borders of law and medicine, I was struck by how differently law and medicine treated certainty. At Yale Medical School students learn that if they look wide enough and deep enough, they will come up with an answer. By teaching that there is only one truth, we feed the greed for certainty. Yale Law School more genially proclaims the varied meanings of truth. They use the case method there: after a case has been discussed and a framework for judgment found, the instructor may ask, "Well, what if the man had been a woman? How would that change things?" Then the discussion begins all over again. Yale’s medical school teaches certainty with confidence where its law school teaches uncertainty with arrogance.
The trouble is that almost everything has been turned into a disease , which has to be seen or scan. Physicians believe that almost every symptom has an organic basis if you try hard enough to find it and if your instruments are up-to-date. Ignoring metaphorical laments like "I've had it up to here!" Or "I can't take that any more of that!", gastroenterologists are convinced that nausea , for example, always arises from delayed gastric emptying. They do not like to consider that nausea could indicate revulsion at the dilemmas or struggles that patients find themselves in, what used to be called the psychosocial aspects of medicine.
"The eye is for accuracy, but the ear is for truth". It is easier to make diagnoses by CAT scan or MRI if you have an eye for patterns than to listen to the patient, to revive what the Greeks called catharsis . Medical treatments are vastly better now than 60 years ago, but it is too bad that physicians have forgotten how much they can do for the patient by being here, by their words and even by their person
CONCLUSION
I come finally to what we can do for the physicians, without whom nothing. My theme has been that the growing power of computers with their extraordinary linkages and memory makes the duties of physicians easier, but more time-consuming. The human aspects of the care they can give will constitute an essential element in 21st-century medicine.
But physicians need help and protection Doctors will always make mistakes, will always have doubts about their own competence and will always feel unworthy at the early death of a patient. Increasing the number of doctors or physician-extenders will give them time for those human duties, enough time to do a good job, and to have some leisure for recreation and contemplation. Physicians are human, will make mistakes and more than rarely will be frustrated and angry and even bitter.
Physicians are experts licensed by the state and they should be protected against unwarranted malpractice suits. If that is not done soon, physicians will increasingly regard every patient as a potential plaintiff and will continue to order every test in the books—and some not yet there. Along with that, however goes some chastisement for those doctors who do not work carefully and loyally enough for their patients. After all is said and done, to a 19th-century physician the life of the 21st-century physician would look pretty good!
I have talked of science that measures and of intuition that comes unbidden. While science explores the universe of the cell, we physicians will learn more about our patients and ourselves if we include what is not seen in our calculus. Modern medical science has left too many physicians feeling that they are only conduits of other powers, of pills and procedures. Managed-care that treats physicians and patients as modules reinforces that error. Protocols and “evidence-based” pathways that I have doubtless maligned assert it.
Our words are the key to our place and our power. Suggestion plays a powerful role in the placebo- response, expectation and faith strengthen that response. Words can exhort the healthy: just as speeches fire us to war or melt us to tears. Rhetoric it used to be called. Words can mobilize healing in the sick, even if science is needed for cure. That must be why medical journals have opened their pages to poetry and narrative, philosophy and faith.
Physicians must recognize once more that not all pains come from disease. What patients learn to call pain to get our attention comes from anger, fear, tribulation, and the silence of sorrow that has no tears. Words of reassurance can alter the vigilance with which people regard their bodily sensations and their perception of their health. If we are lucky sometimes our explanations can provide "the healing fiction, the meaning that quickens". Understand, I'm not suggesting lying, but optimism and hope can help.
Mainstream physicians should not be afraid to rely on suggestion as therapy, words that can be taken in as readily as our pills. Science and intuition are not mutually exclusive. Physicians need not feel guilty at turning to the magical side of their work for part of our magic lies in caring for the patient. On that interdependence hangs the healing of spirit and mind. Neurobiological pathways may run from brain to toe, but I halt at the belief that the mind can control disease. The modern loss of faith leaves us yearning for visions of Paradise. Healing comes from the Creator however named and framed, but in our workaday world there are no miracles:cures comes only from science and technology. All the talk in the world will not release the schizophrenic as readily as modern chemistry. All the love in the world has not very often cured cancer. The onslaught of cancer is like the force of a fire hose that sweeps all before it. The mind can control normal physiology just as you can shut off a garden hose by squeezing your fist, but the power of pathophysiology which is disease requires methods more potent than hope.
In closing, let me thank you for your patience, but let me leave no doubt that I feel blessed to have been a physician. I would jump at a second chance! I might choose neurobiology, but I would certainly choose patient care, to feel useful. Spiritual arrogance it may be, but it's not a bad feeling at the end of the day -- or at the end of a life.
This article was first presented as the Davies Scholar Lecture at the American College of Physicians annual meeting, New Orleans, May 2004.
Published: August 19, 2004