There was a time when medicine was referred to both as a science and an art. In antiquity the art part took precedence since individual experience as well as empiric observation formed the basis of the practice of medicine. Well into the last century, medicine was much more of an art than a science even though basic subjects were taught in formal medical colleges and schools.
However as science progressed so did medicine. During the latter part of the last century there emerged the concept of “evidence based medicine”. What this meant was that rather than personal experiences of individual practitioners, collective wisdom based on “controlled studies” and investigations started to take precedence. What used to be called ‘clinical acumen’ almost became obsolete and different types of tests became the basis of diagnosis and treatment.
When I hit medical college in the mid 1960s, in my house there were text books of different medical subjects that went back more than thirty years. The earliest ones were those that were read by my oldest uncle who graduated from medical college in 1935. Then came the ones that my mother and father read when they attended medical school in the late thirties (LSMF) and the early forties. And finally there were those that my father read when he went on to complete his medical education and receive his MBBS degree in 1955.
Reading the earlier books on medicine was always fun. The text book of medicine that my uncle read in the thirties was a little more than a couple of hundred pages and almost all medical treatments included rest, proper diet, aspirin, opium in some form and laxatives. The books my parents read were in the transition stage, the only new thing was the discovery of ‘sulfa’ drugs that were the earliest antibiotics. Even though Penicillin had been discovered it was not yet widely available.
By the time my father went on to complete his MBBS degree in the mid 1950s, medical treatment had advanced considerably. Besides the availability of Penicillin and sulfa drugs to treat infections, Streptomycin the drug that could treat Tuberculosis had also been discovered and was being used for that purpose. An interesting thing was that when I compared my textbooks that I read a decade later on things like human physiology (how the body works); there was not much of a difference. However the textbooks of medicine I read were now into more than a thousand of pages!
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By the time I graduated from medical college in 1970, three important changes had happened in medicine. First was the transplantation of organs starting with the kidney and culminating in a heart transplant in 1967 by Christiaan Barnard in South Africa. Along with development of organ transplantation came the concept of ‘immune system’ that would reject a foreign organ after it was transplanted; how to suppress this ‘rejection’ was developed.
The second important change was that cancers could also be treated by medicines. I still remember the day as a final year student in medical college when my professor of obstetrics and gynaecology told us that a cancer called ‘chorio carcinoma’ could now be cured by a medicine called Methotrexate. Many cancers can now be controlled by medicines. Before the advent of such treatment, the only possible treatment for most cancers was surgery that was often extensive, disfiguring and debilitating.
The third important change was the emergence of tests and investigations that could help in the establishment of diagnosis and subsequent treatment of patients. When I was a medical student, things like CAT scans, MRIs, Echo and ultra sounds were not yet discovered. Still, most of us graduating at that time had started reading American textbooks that emphasised the scientific basis of medicine and sort of discarded the concept of medicine as an art.
During my years as a practicing heart surgeon in the US, I could ask for a heart echo, a cardiac catheterisation, a CT scan, an MRI or some other test and the results would provide both a diagnosis and determine treatment. All this without even having to lay a hand on the patient.
In 1970 I went to the United States (US) for my advanced training in medicine. Over the next decade, medical tests became ubiquitous. During my years as a practicing heart surgeon in the US, if I wanted to find out what was wrong with a patient having a heart problem, I could ask for a heart echo, a cardiac catheterisation, a CT scan, an MRI or some other test and the results would provide both a diagnosis and determine treatment. All this without even having to lay a hand on the patient.
With the emergence of laboratory investigations as the mainstay of determining the cause as well as the treatment, two things happened. First was that there started to develop a ‘distance’ between the doctor and the patient. This was formalised a few decades ago in US when physicians officially became ‘providers’ and as such they became like any other provider of health care be it a nurse or a pharmacist. The second important change was that all the new technology as well as newer and more complicated forms of treatment had to be paid for and this tremendously increased the cost of treating patients.
The modern concept of ‘evidence based medicine’ has made things worse. It is now presumed that every physician wakes up every morning as a ‘tabula rasa’, reads the latest reports about new ways of doing things and then practices medicine based upon that information. That is of course totally incorrect. Most importantly, even in this era of “modern medicine”, many physician groups are starting to re-emphasise the importance of personal experience and the intimate relationship between a treating physician and the patient.
What we are seeing today is a fight for the ‘heart and soul’ of medicine. On one side especially in the US are aligned bureaucratic forces supported by non-physician providers that want to create a system of medical care based on published data that can be reduced to ‘protocols’. These protocols can be followed even by nurses or other ancillary medical personnel. On the other side are physicians that wish to re-establish their primacy when it comes to patient care.
In the extremely expensive and lucrative medical marketplace in the US, the federal government and private insurance companies along with hospitals try to minimise the role of doctors and save money. Many ‘onlookers’ in this fight presume that all this is just about money. It is about money in as much that modern medical treatment as I pointed out above has become much more expensive than it was in my father’s generation. And those that have to pay for medical care want to cut down costs. But ignoring the experience and perhaps the wisdom a doctor accumulates after years of medical practice still remains a vital part of the care of a sick patient.
Perhaps one anecdote might suffice to explain my point. During my training in cardiac surgery, I was called to give evidence in a ‘malpractice’ case against a senior surgeon. The patient had developed post operative problems that required a re-visit to the operating room. The patient eventually did well. The plaintiff’s lawyer asked me, doctor is the bypass operation a difficult operation. I said yes it is. At this the lawyer seemed excited but then I added, after a few thousand, it does become a bit easier.
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