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Physician, Broaden Thyself

Daedalus Winter 1977, volume 106, number 1. The American Academy of Arts and Sciences, $2.95.

By George K. Sweetnam

BACK IN THE DAYS of antiquity, when Hippocrates taught medicine, it was a sin for a doctor to treat patients with anything much stronger than a shot of honey and water or a dose of strong laxative. But a couple of millenia later, upstart science started to push treatment past the limits prescribed by the Father of Medicine. The discovery of germs in the late 1800s finally toppled most of Hippocrates' cautions. Lab men found drugs that could enter the body and destroy the vile little creatures where they did their dirty work. Disease was something to be attacked without mercy.

After the successful use of such new wonder drugs as penicillin during World War II, medical research rode forward on a wave of federal funding. Sooner or later it was going to track down God, dissect him, and put a schematic of His vitals in a special anatomy text appendix. God seems to have fled the scene, though--the Great Dissection never came off.

Science alone cannot zero in on contemporary problems so easily. Most of the germ-caused diseases are well under congrol in the U.S.; the main causes of death now are heart disease and stroke, cancer, and accidents, homicide and suicide. Such ills can not be eliminated with simple drugs. They are not bugs inside the body--they are in fact hard to separate from the body, and are caused by factors like aging, stress, and hazardous chemicals in the environment. Relieving stress takes compassion. Keeping the environment clean requires social and political action.

The need to reassert humanist considerations in medicine is a recurrent theme in the latest issue of Daedalus. The journal includes essays by 20 of the most influential members of the American medical establishment on the state of their art and of health care in general. Steven R. Graubard, the journal's editor, writes that the issue is a first step towards redefining America's health problems. But the problems already have been redefined. The major obstacles to health have changed without sanction from the American Academy of Arts and Sciences. While the Daedalus articles do not present any very new or unique ideas, they do collect a large body of information and respected opinion on current health problems. And it carries the tone of authority that accompanies the credentials of its contributors--medical school deans and professors and prominent social scientists.

FOUR HARVARD Medical School doctors have pieces in this issue. Dr. Robert H. Ebert, dean of the Medical School, recounts the history of American med schools, but he also makes some recommendations for changes in the structure of medical education. He says there is no need to separate pre-med work in college from the basic science studies of th first two years of med school. If the two phases actually were joined, however, the heavy emphasis on science that would result could hardly open the aspiring physician's eyes to the importance of integrating social and humanist considerations into the practice of medicine. Forcing pre-meds to study a range of subjects as undergraduates may not make them feel much happier about humanities and social sciences, but tracking them into biomedicine earlier certainly will leave them still less skillful and even more ill at ease in dealing with patients' nonscientific ideas and feelings.

Ebert criticizes America's teaching hospitals for pursuing narrowly specialized care and research. This point is very important. All doctors receive some training in teaching hospitals, and the hospitals' emphasis on highly technical and specialized care often means that primary care is treated as a second-rate area of practice in physicians' educations. One of the main problems contemporary medicine is that too many doctors deal only with one area or function of the body and not enough look at the whole person, including the person's social background and life history. The latter kind of physician, working with specialists' advice, has been shown most likely to make the correct diagnosis. The primary care physician is also more likely to provide emotional support to a patient, when often that comfort alone will improve a patient's health.

Dr. Leon Eisenberg, Presley Professor of Psychiatry, affirms in an essay on "The Search for Care" that if medical faculty do not convey the importance of primary care, it will be regarded as "trivial, boring and beneath the dignity of a professional physician." He also points out, however, that many of medicine's apparent shortcomings result from patients' expectations that emdicine will fill emotional needs once taken care of by more cohesive families and stronger religious faith. No simple policy decision can make families tight or churches popular. While doctors cannot be expected to replace these institutions, it would be wise to see that doctors feel comfortable in human relations.

Dr. Stanley J. Reiser, assistant professor of the History of Medicine, writes that life-sustaining devices like the artificial respirator and the kidney machine pose issues still further from technological solution--the moral choice of how long to support a patient on the edge of death. The scarcity of many sophisticated medical services relative to the demand, Reiser writes, raises also the moral dilemma of how to distribute those services. With an historian's pleasure, Reiser points out that to use these latest scientific advances man must look to ethics, one of the oldest disciplines. Medicine the science has in many areas reached a limit which it can pass only as medicine the art.

The "redefinition" of health care in the latest Daedalus points up a growing recognition among the medical establishment that more pure science is not always better medicine. The increasing emphasis on human understanding in medicine may now prove as important in improving health as the hot pursuit of science already has.

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