Medicine: An Uncertain Art

by Danielle Ofri
New England Journal of Medicine

Review of “The Uncertain Art” by Sherwin Nuland.

 

The relentless “scientification” of medical training in the past century has laudably taken medicine far from its roots in hucksterism. Each generation of physicians is steeped in an ever-expanding universe of medical facts. Evidence-based medicine, randomized-controlled trials, clinical prediction rules, and treatment algorithms reassure today’s medical trainees that physicians have indeed evolved from the shamans and that we are purveyors of science, just like our colleagues doing bench research. The hallmark, in fact, of the newly minted doctor, fresh out of residency training, is confidence—not just in his or her abilities, but in medicine itself. But as surely as the first malpractice insurance bill lands on the desk, so too does the awkward lesson of clinical medicine— that the scientific certainly dished out by the medical establishment represents only a minority of what clinical practice actually is.

It is this uncomfortable lesson that Sherwin Nuland attempts to explicate in his latest book, “The Uncertain Art.” Having traversed a half-century of active clinical practice, he is able to cast the long view over the field of medicine. After paying his dues at the bedside and in the operating theater, Nuland has the credibility, the thoughtfulness, and the time to step back and think about what we physicians do daily, sometimes rotely. Perhaps it is because of this roteness, or maybe it’s simply because of the sheer time crunch, that we rarely stop to consider what we do and don’t know. And for sure, we almost never ponder how certain or uncertain our knowledge is. Not only is it time-consuming to do so, it’s also relentlessly unsettling. “The single certainty is uncertainty,” Sherwin Nuland reminds us. “Only the reliability of unreliability is to be relied upon.”

In the introduction to “The Uncertain Art,” Nuland reports that he is attempting to “stake out a territory whose boundaries are sufficiently vague that I may feel free to roam wherever inclination lead me.” And roam he does. Reading Nuland’s book is like sitting on a park bench with an avuncular storyteller of the renaissance type, who cheerfully pulls one anecdote from his pocket after another, each story linked to the next only by the fact that he finds them interesting and that he knows something about them and that you might find them interesting too.

The chapters in this book are a series of essays that Nuland wrote for the American Scholar, the august journal that was then in the editorial hands of Anne Fadiman. A collection of separately-written essays, by nature, lacks the cohesive spine of a larger, more focused work of nonfiction. But if you relax, lean back on that park bench, and be ready to roam with your storyteller, there’s no telling what you might stumble upon.

You might learn that one of Hippocrates’ illustrious Aphorisms was, “The bald are not subject to varicose veins.” Another was “Stammers are particularly liable to obstinate diarrhea.” Hmmm, and you thought you understood that oath you took at graduation.

You might learn that black bile, the fourth of the famous four humors, didn’t actually exist. The other three humors—blood, phlegm, and yellow bile—were obvious to any observer of human secretions. A fourth humor had to be invented to satisfy Empedocles “notion of fours,” a reigning philosophy in the fifth century. “No one knows who hit on the idea of black bile,” Nuland observes, “but it sounds like the kind of thing dreamed up by a committee.”

You might learn that enemas were invented by the ancient Egyptians, and that the highly-respected physicians who assisted the Pharaohs with maintaining regularity were known as Shepherds of the Anus. Try that one out on your fellow gastroenterologists at the next drug company dinner.

You might get a chuckle in hearing the esteemed Dr. Nuland referring to the “the pecs and abs” he developed when he started pumping iron at a later stage in life.

I was fascinated to learn that the major critique of Henry Gray’s now classic textbook of anatomy came in the form of a book review in none other than the New England Journal of Medicine. This particular book review took up half the pages of the journal in two successive issues. (We modern reviewers get only 1200 words.) The reviewer, who signed his name only as H, railed against the major heresy of the book, which was to employ illustrations, labeled ones at that. Such diagrams would be “use[d]… at the expense of the text.” Thank goodness book reviewers at the Journal carry little weight, otherwise today’s students would still be learning anatomy in the form of prose.

But beyond intriguing and amusing facts, Nuland probes a number of complex—and yes, uncertain—topics that are extremely relevant to modern medicine. In his chapter entitled “The Medical School and the University,” he writes about the importance of the Flexner report of 1910 that standardized medical education, leading to the closure of the dubious “proprietary” medical school. Medical schools affiliated themselves with universities to achieve the appropriate scientific criteria set out in the report. While this move had the salutary effect of improving medical teaching, Nuland notes the corollary, that “the leaders of American medicine…made an irrevocable decision: the educational institution was also to be a research institution.” Most of us take this for granted, assuming that this is just the way things are and the way they ought to be. But Nuland raises a critical point, that the aims, styles, and personalities of education and research can be quite different, and not always synergistic. Just take a look around the medical school and see who has tenure.

Another thoughtful chapter, “The Man or the Moment,” probes the sometimes messy issue of whether scientific discoveries are unique to the “discoverer” or inherent to the times. Reminding us that individual humanity is inextricably linked to the scientific method, he gives the example of Semmelweis (about whom Nuland has also written a full-length book) who demonstrated how to prevent puerperal fever by washing hands in chlorinated lime solution. But his pugnacious personality prevented his theory from taking hold in 1840. Only decades later, with the mild-mannered personality of Joesph Lister, did antisepsis begin to take slow root. The number of preventable deaths that occurred in the interim is astronomical. It is quite humbling to realize that these deaths are partially attributable to quirks of personality.

The most moving chapter is the final one, dryly titled “Letters from a Heart Transplant Patient.” The only essay not from the American Scholar series, it is the one that is most directly human. In 1987, while preparing for a New Yorker article on organ transplant, Nuland was introduced to George Leyden, a 56-year old man with a dilated cardiomyopathy, awaiting transplant. Nuland casually suggested that Leyden “free associate” at the computer, and send him periodic updates on his condition. Leyden was an IBM executive, not a writer, but his epistolary outpouring is riveting. Nuland deftly intersperses Leyden’s writings with his own observations. We are brought from the outer edges of observation into the deepest meat of real patients and real lives, and it is here that we experience the uncertain art at its most disquieting. The philosophical agony of knowing that the saving of his life will occur only at the demise of another’s is vividly described by Leyden, as is the corrosive effects of waiting. “If mental agony can create a better man,” Leyden writes, “then it won’t be long before I am one terrific guy.” We, like Nuland, are crushed when Leyden dies, still on the waiting list. It is here that the uncertainties of medicine enrage us.

You may not be able to absorb all the stories in this book in one sitting at the park bench, but it’s a treat to be able to return frequently to that bench, taking time out from the latest JCAHO mandate that your hospital is scurrying to fulfill, and listen to an experienced raconteur spin out another one.    (from the  New England Journal of Medicine)