CEHL:

Diagnosis at the Bedside of Modern Medicine

by Dr. Jerome Groopman
December, 2003

Foreword

Both writers and patients share the struggle of putting feelings into words. So, when we discovered a Boston Globe book review that summarized what we hoped our web site might accomplish, it seemed like marvelous good luck.

Dr. Jerome Groopman, in his review of Richard Horton's book, "Health Wars: On The Global Front Lines of Modern Medicine," published by the New York Review of Books, takes on the task of reaffirming the culture of health caregivers and argues for solutions as to what is wrong with medicine today.

Dr. Groopman is very qualified to champion the enormous contribution of evidence-based medicine alone. He holds the Dina and Raphael Recanati Chair of Medicine at the Harvard Medical School and is Chief of Experimental Medicine at the Beth Israel Deaconess Medical Center, where he established an innovative program in clinical research and clinical care. However, despite the positive outcomes of evidence-based medicine, Groopman suggests the following:


"Modern medicine is ailing … the traditional esteem and authority accorded to health care professionals have been lost, and until these attributes are restored, the commitment of doctors and nurses will continue to whither …"


Groopman highlights Dr. Horton's assertion that the current emphasis on marvelous science overlooks the soul. In addition to paying attention to disease, a physician must understand his patient's anguish, his "dis-ease." These two physicians teach us that, if medicine is to retain its place as society's chief source of healing, it will require a subtle alchemy of intuition, the narratives of the patient's life, and time, the most precious commodity of modern medicine.

Groopman closes the review by presenting Horton's challenge that


"the role of the doctor must be to alleviate dis-ease … to have the quiet humility to listen … to act as the voice of one's patient through advocacy, … and to take on the opportunity of restoring human dignity, which is the essential fabric of modern medicine."


The following are excerpts from Dr. Groopman's review of "Health Wars: On The Global Front Lines of Modern Medicine" by Richard Horton, MD. Comments and subtitles are mine.

- Howard S. King, MD




Something is seriously wrong with modern medicine

"Modern medicine is ailing. Something is seriously wrong. This is felt not only by patients, but also by doctors….Yet there is disagreement about the diagnosis of medicine's malady.…The traditional esteem and authority accorded to health care professionals have been lost, and until these attributes are restored, the commitment of doctors and nurses will continue to wither." It will require the reaffirmation of the culture of caregivers. What is that culture?

The explosion in scientific information

In reviewing Dr. Horton's book, Dr. Groopman addresses that question. "Horton's primary thesis is expressed by a play on the word 'disease.' Doctors are trained in medical school and residency to focus squarely on the diseases of their patients. The explosion in scientific information…has made this focus even more sharp and penetrating. While in the past physicians relied heavily on the spoken history of symptoms offered by the sick and their families, and then pursued these clues in the bedside examination…technology now permits the physician largely to skip such time-intensive practices and jump to a CAT scan to visualize the inner anatomy of the patient and to DNA analysis of his tissues to pinpoint what is wrong."

Yet modern medicine overlooks the need to understand the patient's anguish

"Horton asserts that this concentration on marvelous science overlooks the soul. In addition to paying attention to disease, he says, a doctor must understand his patient's anguish, his 'dis-ease.'

This position, Horton emphasizes, goes against the tide of so-called evidence-based medicine. And evidence-based medicine is all the rage these days, the core of medical school curriculums at our most prestigious institutions. 'Evidence-based medicine is a movement that aims to quell what its more extreme supporters see as two malevolent attitudes in medicine,' (Horton) writes. 'One is that the favored basic science for medicine is done in the laboratory. Respectable medical researchers point themselves toward the bench, not the bedside.…The other attitude concerns the power of and respect for the clinical professor, awarded by virtue of his or her long experience….'

Yet humans are not consistently rational beings, and the physicians who practice medicine and the patients who receive care are both deeply human. Horton shows how powerful the irrational is in our public health, and how feeble 'evidence' may be in influencing the salubrity of society."

Experience is out because it cannot be measured.

" 'In our new quantitative world-view of medicine, experience is "out" because it cannot be measured, packaged, examined, manipulated or tested experimentally or statistically. Experience exists only in the mind. In hierarchies of valid evidence, experience sits at the bottom, the weak associate of scientifically acquired evidence.' "

Nevertheless, intuition needs to be a potent factor in diagnosis and treatment …along with the clinical narrative

But, "Horton rejects this trend, and asserts that intuition, how a doctor 'feels' about a patient and his condition, needs to be a potent factor in diagnosis and treatment: 'intuition is about as unscientific as one can get in writing about reliable evidence. But in medicine, in many practical disciplines, intuition is a powerful tool in the right hands.' "

In the meantime, "clinical care pivots on narratives, the narratives of the patient's life, that link his past to his present and that project his future. Such narratives fall outside of statistically analyzed experimental evidence, the evidence that this generation of doctors is taught to primarily invoke when offering options for treatment."

They both require time, perhaps the most precious commodity in modern medicine …

"To reincorporate narratives into the doctor-patient encounter, and to provide the fertile environment for intuition, requires time, perhaps the most precious commodity in modern medicine. There seems to be scant time afforded to allow a patient to speak in what is often a disconnected and seemingly meandering way, but which can reveal key clues not only about an underlying physical condition but also his beliefs, attitudes, and needs."

"…it is a person's beliefs, attitudes, and state of mind that will determine how he readily he follows a treatment regimen and how successfully he can endure an illness." Horton writes, "It is time for time, and the judgment that it permits…to be taken more seriously. This change is necessary if medicine is to retain its place as society's chief source of healing. It is by no means certain that it will do so."

The essential role of human dignity and the humility to listen

Finally, Horton "makes an argument that human dignity should be the essential fabric of modern medicine….'Medicine is an important lever for restoring human dignity, at the bedsides of the sick….The role of the doctor must be to alleviate dis-ease as well as disease, to have the quiet humility to listen when faced with pervasive anxiety, to have the strength to give sustenance when faced with despair, and to have the confidence to act as the voice of one's patient…through advocacy, when faced with vulnerability and powerlessness. The restoration of dignity is the end common to all of these endeavors.' (Italics mine)

'Amid the many exaggerated scientific claims and harsh political debates that characterize much of modern medicine, this simple idea, so easily overlooked, is the fundamental reason why medicine matters, and why we need to take human dignity a great deal more seriously than we do today.'"

In January 2004, Dr. Groopman published "The Anatomy of Hope: How People Prevail in the Face of Illness" (Random House) which explores how hope can change the outcome of illness.

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Support

I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.


- Dr. Howard King, M.D.