Early history of medicine

No historian can determine when the “profession” of medicine began. But the earliest recorded accounts of physicians were circa 2500 years BC found in ancient Egyptian scrolls and writings in which “physicians” were recognized as necessary to protect and prolong the lives of the ruling pharaohs. Although early physicians could offer first aid, perform amputations, and apply plasters and various herbs and salves, their main role was to use their artful powers to help their patients cope with their maladies. Aesculapius (ninth century BC) believed that reptiles, especially snakes, possessed secret healing powers, which many historians believe was the forerunner of our medical symbol, the 2-snake Caduceus. And Hippocrates (460-377 BC) was known for his discourses on the “art of medicine.” He wrote that medical art consists of 3 main factors: the disease, the patient, and the physician.

During the centuries through the Dark Ages, most medicine was practiced by religious healers/physicians who relied on their deities to soothe and heal the ill. Not much changed in the knowledge and practice of medicine until the Renaissance in the 15th and 16th centuries. Leonardo da Vinci (1452-1519) studied and illustrated human anatomy and some diseases such as goiter, syphilitic skin lesions, anatomical deformities, and even childbirth and fetuses in the womb.

Paracelsus (1493-1541), the “wandering physician,” traveled all over Europe to learn different aspects of medicine and learned to use different metals as drugs. But more importantly, he was a psychiatrist and, as noted in my opening quotation, he felt that medicine was a divine mission and proclaimed that the character of the physician was as important as medical skills.

In 1551, England’s Dr Thomas Linacre became the first president of the newly founded Royal College of Physicians and is credited with the first significant actions to lift the practice of medicine into a profession and officially link humanism with the new developments in the science of medicine.

Over the next 3-4 centuries, there were many more individuals who contributed to advancing knowledge of human anatomy and physiology. One of the most important series of advances (in my opinion) were the invention and development of the microscope, which led to the discovery of microscopic bacteria by Von Leeuwenhoek (1632-1723), which Pasteur (1822-1895), studying microbiology, used to explain the germ theory of diseases. Lister (1827-1912) picked up on this to treat pus formation on wounds with carbolic acid (phenol). Another major discovery in the 19th century was the use of ether as an anesthetic agent, which allowed surgeons to advance their skills and techniques.

But even with the rapid advances in medical science, Dr William Osler (1849-1919), who many feel was the “father” of modern humanism in medicine, emphasized the importance of art of medicine in his many writings, including the “Principles and Practice of Medicine” and the “Aphorisms.” Initially at McGill and later at Johns Hopkins, he wrote and taught that the patient should always be the center of attention, and he pioneered the medical residency concept and emphasized that the students learned more about medicine by spending time seeing and talking with the patients than from didactic lectures. This idea caught on rapidly and soon courses in the doctor-patient relationship were taught in most English-speaking medical schools.

Modern history

Because of the rapid advances in science, in 1904 the American Medical Association formed the Council on Medical Education (CME) whose objective was to restructure American medical education to emphasize the “science” of medicine. Among other issues, the CME established formats as to how medical schools structured their education. They set up the requirements for 2 years of science, followed by 2 years of clinical work in teaching hospitals, which, of course, is still the program used today.

In 1908, the CME asked the Carnegie Foundation to perform a survey of medical schools to promote their reformist agenda. A professional educator, Abraham Flexner, was appointed to do the study, and the report he released in 1910 created the single model of medical education. Although the Flexner Report reforms were very much needed, 1 of the concerns was that the emphasis shifted medical teaching to the “science” of medicine and away from the humanism of medicine.

The science of medicine advanced rapidly in the early and mid-1900s with the advances of surgical procedures and improved management of many medical conditions. Vaccinations virtually eliminated smallpox and reduced the frequency and severity of many other infectious diseases. The development of antibiotics in the late 1930s was a tremendous advancement. And the discovery and development of X-rays advanced diagnostic ability. These scientific advances were important in that they improved the physician’s relationship with their patients because they provided relief of symptoms and cures not available to past generations.

However, the rapid advances made in diagnostic techniques beginning in the early 1970s such as ultrasound imaging, computerized axial tomography scans, magnetic resonance imaging scans, and advanced laboratory testing began to erode the doctor-patient relationship. Many physicians began to rely more on these tests to make a diagnosis and thus became less observant of the patient’s actual medical problem. Humanism and the art of communication and physical examination became less important and in some cases ignored altogether.

Dr N. H. Tucker III, president of the Jacksonville Medical Society, in a 1999 editorial titled “Medicine: art versus science,” expressed concern that the “… medical pendulum is swinging from the art to the science of medicine.” And Dr Richard Bulger notes in his excellent book, Quest for Mercy , “… as science continues to advance at such a rapid pace, it would be a shame to pass on the compassion and communication with patients to nonscientific healers.”

Many others have expressed similar concerns. Dr Bernadine Healy, former head of the National Institutes of Health, wrote an excellent essay titled “Medicine, the art” in her “On Health” column in U.S. News & World Report in July 2007. She noted that although we do not hear much about the art of medicine these days, the art of medicine transcends all else when an anxious individual confronting death or disability looks to the physician for answers as to what is the best course to take.

She stated that the art of medicine is based on 4 principles: mastery, individuality, humanity, and morality. Because of the 1 page limit for her piece, she could not expand much on these. So I will.

Mastery involves expertise, wisdom more than knowledge, and a creative way of thinking. But until just recently the main emphasis has been on knowledge and continued learning. This principle has been aggressively pursued by medical education, continuing medical education, and all of the accrediting agencies that oversee medical practice. What may not be emphasized enough is the mastery of the doctor-patient relationship, which is facing some definite road blocks.

Today’s doctors are burdened by many pressures that limit their relationship with each patient. One is time. A busy doctor today finds it very difficult to sit down and spend a significant amount of time finding out what a patient’s problem is. Dr Jerome Groopman, in his book, How Doctors Think , notes that a study by several researchers who studied thousands of videos and live interactions between doctors and patients found that on the average physicians interrupt the patient within 18 seconds of when they begin their story. Why does this happen? For one, doctors can not adequately schedule their time allotments for each patient because of the unknowns. This is especially true in our specialty because we frequently get called away for an emergency such as a delivery or a call to the emergency room.

But another major factor is how doctors are paid. Most third-party payers do not pay much, if anything, for time spent talking with a patient. In a July 1984 editorial in the Journal of the American Medical Association , Dr Norman Cousins, dean of the University of California, Los Angeles, School of Medicine, addressed this issue and reminded us that “some of the most useful clues in cracking a difficult diagnosis not infrequently emerge from a patient’s responses to careful questioning.” Dr Groopman expands on this in his book in which he describes numerous examples of actual cases when doctors made snap judgments regarding a diagnosis, which was subsequently wrong.

Although new coding for billing is helping the payment for talking, many physicians still feel that it is necessary to order tests, perform procedures, and see as many patients as possible to maximize their revenue and minimize their medical liability risks. This is a significant contributor to the high and rising costs of health care. Hopefully this will be changing with improvements in health care payment systems. But I would not bet on it.

Individuality of each patient is important to understand in that no 2 people are exactly alike and no 2 diseases or maladies are exactly alike. We all know of examples of patients with breast, uterine, or ovarian cancers that histologically look the same but respond differently to the standard treatments.

It is also important to believe that not all people with a disease are necessarily ill. Dr Bulger opines in his book that people are ill when they suffer from a disease. That is, disease plus suffering equals illness. One patient with a particular disease may not “suffer” from this and has learned to accept the diagnosis and do the necessary things to minimize the effects whereas another patient may suffer emotionally and psychologically. The latter is defined as ill and requires respect and compassion from their doctor. And Dr Bulger opines that “suffering is maximized when patients feel that they are not respected by their caregivers and others around them.”

Humanity depends not on what a physician knows but who they are. Humanity requires a compassion for who the patient is and the ability to focus on the patient using language and explanations that the patient can comprehend. So often I have witnessed physicians discussing a medical problem with a patient in complex medical terminology that goes right over the patient’s head.

Compassion also requires understanding what a patient wants and needs to know. We all know that some patients express a desire not to know much about their problem, and others want to know everything. It is the art of the doctor to recognize and understand this and respond in the best way possible. Also, patients often do not fully understand what you, the doctor, know about their condition, and thus, it is imperative to allow them time to ask questions and not to express verbally or nonverbally that you think their concerns are stupid or not important.

And then there are situations in which the news is bad. Giving bad news to a patient is never easy and must be well thought out before proceeding. Humanity requires more than words; it also requires an understanding of where the patient and the patient’s family are coming from. Some are anxious to know right up front what the situation is, whereas others may not be ready to process bad news right away.

Morality is important in that it provides a degree of trust in a doctor by patients who feel vulnerable with their inner feelings and privacy. This involves communication skills that focus on the patient to assure that they are being told the truth, are not being taken advantage of, or feel that they are being forced into a specific treatment or surgical procedure.

Morality does not mean physicians should impart their own moral beliefs based on their religious or other doctrine when making medical decisions for the good of the patient. It does mean presenting all of the facts to the patient regarding the medical problem and present options and recommendations for the management and treatment. If the patient chooses not to accept the primary recommendation, the physician should be understanding and offer more time to think about the situation or to have a relative or friend come back with them to discuss it.

Other options such as a second opinion or a trial of a more conservative treatment can be offered. If this approach is done, it will often pay off in the long run, and the patient will be more trusting and will be more satisfied if, or when, they eventually choose the doctor’s initial recommendation.

And probably the most important aspect of morality is patient confidentiality. We must be very careful in how we log certain personal issues in the patient’s record. These issues might have an important barring on the patient’s condition but could be very damaging emotionally and psychologically if they were intentionally or unintentionally leaked out. Hopefully developing electronic medical record technology will provide for a secure site for confidential information.

I am sure that most, if not all, of what I have just presented is not new to most of you in attendance. But I can assure you that there are many practicing physicians who do not practice artful medicine either because they do not know how, or they choose not to. In my small town practice in Hanford, CA, I saw many patients over the years that had been mismanaged, misinformed, and/or misdiagnosed. Almost every 1 of these was because the initial physician did not get an accurate history, perform an adequate examination, or recommended treatment that was inappropriate and sometimes harmful.