Medical Musings

“Therefore, send not to know for whom the bell tolls. It tolls for thee.”

John Donne

I would like to thank the class of 2008 for the opportunity and honor of speaking with you today and also to thank the Arnold P. Gold Foundation for sponsoring this important event. This is what most, if not all, of you have been waiting for. The chance to finally leave the classroom and apply the knowledge you have been accumulating to the care of patients. It is an important milestone in your careers. The responsibilities we bear are enormous but the privilege with which we are entrusted is even greater.

When I first received this invitation, the very first thing that came to my mind is a well-known saying, “La médecine c’est guérir parfois, soulager souvent, consoler toujours” which translated means “to cure sometimes, to relieve often, to comfort always”. This aphorism has been attributed to the famous French surgeon Ambroise Pare but recent scholarship suggests that it had been roaming through medicine for centuries. It emphasizes that while curing is important, albeit inconstant, caring and comforting are always the healer’s objectives. I hope that this sentiment will always guide your interactions with your patients as you continue in your careers.

What is “humanism”? The Oxford English Dictionary has five major definitions of the word humanism. The one which is germane to our field is, “The character or quality of being human; devotion to human interests”. As I thought about humanism in medicine, I was struck by the fact that it was even necessary to discuss humanism and its role or place in the healing arts. Is it not implicit that the practice of medicine is, above all, a human endeavor which brings the physician and patient into a deep and, at times, almost mystical relationship?  A relationship in which, at times, the patient shares some of her deepest concerns and hopes with her physician, trusting that that physician will accept her unconditionally and do his utmost to help heal her be it physically or emotionally. This relationship, of course, flows in both directions. We physicians also get much from this relationship . The essayist Anatole Broyard reflecting on his own experience as a patient, wrote, “Not every patient can be saved, but his illness may be eased by the way the doctor responds to him – and in responding to him the doctor may himself be saved.”

Now to be perfectly honest, there are times in which some patients can be frustrating and exasperating and one may wonder why one has ever agreed to take them on as patients. However, I assure you that, at times, your patients will be frustrated and exasperated by you and will wonder why they ever came to you in the first place. That is the nature of human relationships and, in my opinion, does not detract from them. One must always keep in mind that the role of patient can be very difficult. With more severe illnesses, patients often feel helpless and afraid not to mention the sense of not being in control. It is the responsibility of the physician to help the patient regain some sense of control and to give hope, when appropriate. At the very least, the patient must be made to understand that, regardless of the prognosis, the physician will always be there to alleviate suffering and to offer an understanding ear. In my case, I have cared for many older patients for more than two decades and I can assure you that getting older is not for sissies.

There are many reasons why we physicians might lose our humanistic bearing . Medicine is an arduous profession, one which can be physically and emotionally draining. A century ago, Sir William Osler recognized the effects of clinical practice on its practitioners when he wrote, “In some of us, the ceaseless panorama of suffering tends to dull that fine edge of sympathy with which we started. Against this benumbing influence, we physicians and nurses, the immediate agents of the Trust, have but one enduring corrective – the practice towards patients of the Golden Rule of Humanity as announced by Confucius : “What you do not like done to yourself, do not do to others.” In modern day practice there seem to be even more numerous external pressures – productivity quotas, time constraints, mountains of paperwork and streams of bureaucratic red tape, to name a few. Nevertheless, when dealing with patients, one must always remember, “but by the Grace of God, there go I”.

So, does being a humanistic physician entail listening attentively and showing genuine concern? Yes, that is part of it but by no means all of it. Does one place the occasional gentle touch or give an understanding look? That too is important. It is also important to realize that as healers, there is nothing that is beneath you when it comes to caring for your patients. If a patient cannot cut his food, do it for him. If she needs to get on a bed pan, help her to do so. If a patient is nauseated and vomiting, hold his forehead while he vomits into an emesis basin. That patient will more likely remember that act of kindness that the fact that you diagnosed his pheochromocytoma. Sir William Osler, one of the two physicians I admire the most (my father is the other) epitomized the humanistic physician. He had been on his way to a ceremony all decked out his academic regalia when he stopped off at the home of a young boy who was dying of diphtheria and who was not eating. Osler, entered the sick room and sat on the bed by the boy. He spoke to the boy while he peeled an orange and told the boy that it would be the most wonderful thing he had eaten. Piece by piece the fed the lad until the boy had eaten the entire orange. Osler, who was one of the most venerated physicians of his time, returned that evening and did the same thing. He then returned every day, bringing with him his academic regalia, which he slipped on outside of the boy’s room, and then fed the boy an orange. Sir Osler did this twice a day for several weeks and the boy eventually recovered.

What stories will each of us be remember for?

Several generations ago, the proper professional demeanor was of unemotional detachment. Thankfully, we have outgrown that stage. More recently, it has become acceptable, and even desirable, to show sympathy, empathy and emotional concern. And that is good. However, I would like to suggest something even more radical. The mystic poet John Donne wrote in his thirteenth meditation – “No man is an island, entire of itself; every man is a piece of the continent, a part of the main. Ifa clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee”.

What I would put to you, therefore, is that we should love our patients. We are, after all, part of the larger human family. What has dawned on me in the last few years is that our patients are, in a very real sense, our aunts and our uncles, our brothers and our sisters. Treat your patients as you would your family. There has been much written and discussed recently about diversity and the importance of acknowledging and celebrating it. I am all for that. However, there is much more that binds us as human beings than makes us different. I have never met anyone who did not wish to feel needed and loved; who did not wish to feel special and part of a greater whole. I would suggest to you that you should respect our diversity but embrace our commonality.

“Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half—so the most important thing to learn is how to learn on your own”

David Sackett, M.D.

“Nullius in verba” – Motto of the 1660 Royal Society

I had an excellent clinical experience while rotating through the internal medicine service at Cook County Hospital in 1977. I distinctly recall that when making rounds with the chief medical resident, he brought along with him a chart cart with multiple medical textbooks for us to confirm what was being taught.

While reading a recent paper on physical examination findings in endocrine disorders, I came across the famous ‘Queen Anne sign’, also known as the sign of Hertoghe, which describes loss of the lateral third of the eyebrows in some patients with hypothyroidism. I had read, years ago, that this sign was not factual and stopped teaching it to medical students and residents. This got me to thinking about all the things we have been taught in medicine which are not true but have ensconced themselves in the medical literature and have come to be believed as true. This is analogous to the aphorism, “Repeat a lie often enough and it becomes the truth.”

By way of example, I describe a small smattering of medical “truths” which, in fact, are not as a means of highlighting the need to continually reassess what one knows.

1. Evaluation and treatment of acute appendicitis.

As a surgical intern in 1979, acute appendicitis was believed to be a one-time event which required surgery for definitive diagnosis. In 15% of cases, the excised appendix showed no evidence of inflammation or infection. This moderately high false positive rate was felt to be necessary so as not to allow any cases to go untreated (i.e., surgically).

The most recent data on treatment of acute appendicitis is that, barring any complications such as perforation or systemic infection, treatment with antibiotics in low-risk patients is recommended. This represents a change in guidelines based on new data. However, one form of appendicitis I have never heard discussed is of chronic (or relapsing) appendicitis. The literature on this entity is decades old but primarily in European journals. Recurring episodes of appendicitis have been documented in patients with recurring episodes of abdominal pain. I personally have two family members who were found to have chronic appendicitis discovered after they underwent appendectomy while undergoing laparotomy for unrelated reasons. One had recurring episodes of abdominal pain for years which had evaded definitive diagnosis.

2. Roth spots.

Ask any medical student or resident what eye findings are found in infectious endocarditis and they will immediately respond, “Roth spots”. I, myself, taught that for years until I discovered that Roth had never described white centered hemorrhages (the description of what constitutes a Roth spot) in patients with infectious endocarditis. In 1872, he did describe retinal red spots (previously described by Bowman) as well as white spots but not white centered hemorrhages. That description was made by Litten in 1878, six years later. The eponym “Roth spot” is, nevertheless, enshrined in the medical literature. Joseph Sapira, in his exquisite physical diagnosis book, goes into the history of the description of these retinal lesions.

3. Tactile fremitus.

Most of us were taught that to check for tactile fremitus, one should have the patient say “99” while palpating the chest with the palm of the hand. It turns out that this is not ideal but came about because of a direct translation of a German medical paper which advocated having the patient say “neun und neunzig” (i.e., ninety-nine in German) when checking tactile fremitus. The diphthong “eu” creates the sound “oy” which proves to be a more effective way of detecting changes in fremitus than the sound “ine” (in most cases). I, therefore, had patients say “toy boy” while checking fremitus until a resident pointed out that that phrase sounded inappropriate. I switched to having patients say, “oy oy”, instead.

4. Thyroid hormone replacement therapy.

There is a near unanimous consent in the medical field that hypothyroid patients that require thyroid hormone replacement, levothyroxine (i.e., T4) is all that is needed to restore a euthyroid state. Recommending a mixture of T4 and T3 is frowned upon. That was my stance for many years until I read an article by Kent Holtorf, MD who made a very convincing case that that may not always be ideal. Nearly every physician who has taken care of hypothyroid patients has had several who continued to complain of not feeling completely well despite having normal TSH and free T4 levels. This has frequently been explained away by stating that, since hypothyroid symptoms are nonspecific, the patient’s sense of not feeling perfectly well was not related to their thyroid status but to other nebulous causes. The article by Kent Holtorf goes into great detail in explaining the physiology of thyroid hormone action, the varying effects of the three deiodinase enzymes and how there might be a disconnect between pituitary deiodinase activity and cellular thyroid function and the effects of various disorders and states on thyroid hormone activity at the cellular level which are not reflected by the pituitary TSH level. A discussion with an endocrinologist colleague acknowledged that the final say on proper thyroid hormone replacement was still a work in progress.

5. Determining right atrial pressure via jugular venous examination.

This one is my mea culpe. Although I have always been extremely impressed by Dr. Sapira’s textbook on physical examination, I never did review the section on examination of the jugular venous system as I arrogantly felt that I had reasonably mastered the skill. Today, however, I did read that section to my great embarrassment. The method recommended by Dr. Sapira is nothing like the traditional method which has been etched into numerous high-quality textbooks. Dr. Sapira makes a very good case against the traditional method and its landmarks (i.e., the sternal angle of Louis) which he cynically dubs “the cardiologist’s constant”. I will let the reader pursue this topic at his or her leisure.

Maintaining one’s knowledge base and skills in medicine is difficult. Expanding on that knowledge base is very difficult and time-consuming. In addition, confirming the validity of what one already “knows” is nearly impossible. Nevertheless, an effort should be made as often as reasonably possible to confirm that what one knows is, in fact, factual.

For many, Medicine is a calling. I knew I wanted to be a doctor when in my early teens. This was reinforced by the fact that my father was a doctor who, sometimes, discussed his pathology cases at home. The depth and breadth of what he knew was breathtaking and who would not want to be so immersed in and knowledgeable of one’s profession.

Caring for patients can be, simultaneously at times, the most exhilarating, invigorating, edifying, heart warming or heart wrenching experience. At times it can be positively spiritual. It is also, on occasion, maddeningly frustrating and, sadly, the frustrating aspect has been progressively less due to difficult patient interactions and more and more due to the environment in which medicine is practiced.

I have said, and still believe that a doctor should love his or her patients. They become a part of the family and, just as with any family, there will occasionally be that difficult uncle or cousin who drives you mad. Nevertheless, he or she is still your relative and you love them nonetheless.

Forty years since receiving my degree, I have learned and experienced much more than I would have ever imagined, and a significant part of it has not been directly related to the narrow practice of medicine.

I am currently somewhat pessimistic about Medicine’s trajectory. I can see no fruitful remedy unless it comes from doctors and not the bureaucrats, big pharma and/or the government who currently hold the reins. Nevertheless, our patients continue to need us, probably more than ever, and this should be our guiding light.