THE CLINICIAN FUNCTION IN MEDICINE


THE CLINICIAN FUNCTION IN MEDICINE.
THE RT. HON. LORD HORDER, K.C.V.O., F.R.C.P.

Consulting Physician to St. Bartho…


From New York State Journal of Medicine.

Medical literature is enormous and the vast majority of medical books and articles are unreadable and possess no intrinsic value; they are scarcely glanced at by the initiated and are soon forgotten.

However, we find throughout history medical writings few in number of the utmost value, writings which show great originality of thought, keen observation and broadness of view, which will live for all time. Hippocrates wrote 2,300 years ago and most of his writings are as valuable now as they were at the dawn of history. Every valuable now as they were at the dawn of history.

Every experienced physician and surgeon will read with delight and with practical advantage the Hippocratic books, and he will find that his horizon will be widened and he will learn much of sterling value from the Father of Medicine. I have frequently quoted Hippocrates at length in my writings and so have many other medical authors.

Some time ago I read an amazing lecture delivered in New York by Lord Horder. It was an epoch-making paper, and it will live for time. It ought to be compulsory for every medical student to read it, and every medical student should be examined on it before being given his degree. To my great pleasure I am able to reprint his most valuable paper, and I imagine that all my readers, both professional and lay, will read it with pleasure, and will derive from it the greatest possible practical benefit.

Lord Horder, thought very eminent on the scientific side of medicine and thoroughly familiar with the achievements of the laboratories, recognizes rightly that “Nature is the curer of disease”, as Hippocrates proclaimed 2,300 years ago.

His lecture is intended to bring back modern medicine out of the morass in which it has become entangled, and to lead it back to the safe and sound paths which were marked out for future generations by the Father of Medicine. EDITOR, “HEAL THYSELF.”.

OF late years the clinicians function has fallen a good deal into disrepute. I want to analyse, as briefly as may be possible, some of the reasons for this.

The first reason that calls for comment, because it is undoubtedly a potent one, is the development, during the past thirty years, of laboratory methods of diagnosis. The study of the patient, qua patient, has been supplemented by the study of materials derived from the patient. Some of us saw the birth of clinical pathology, and many of us have watched this lusty babe grow up to a vigorous manhood.

As is wont with the virile adolescent, there have been times when he thought himself more important than he really was, when he sought to bestride the whole world of medical knowledge, when he firmly believed he was medicine rather than merely making his contribution to medicine. His incursion into the sick room was apt to be somewhat brusque, not to say at times truculent. Cuckoo-like, he jostled and pushed and oft-times succeeded in ousting his more timid and gentle colleague from the latters legitimate sphere.

He took to describing himself in the telephone directory as “physician”, and he invited the credulous sick to consult him. The public, with its child-like confidence in apparatus, loved him, welcoming his advent as signalling the millennium of exact medicine, and unaware that the human brain is the best machine of all. A catalogue of the flora of the fauces and / or if the faeces, a complete blood count, a chemical analysis of the urine to the third place of decimals: “What further may be sought for or declared?” Not only was the new gospel about to dispel the darkness that shrouded diagnosis, it was about to illumine the therapeutic field also.

The “opsonic index” for an exact diagnosis, the hypodermic syringe, charged with the appropriate antigen, for effective treatment, and medicine was “taped” at last. The clinician came to be regarded by some with amused tolerance; by others, even less generously minded, as obstructive to real progress. Nosology disappeared and pathology contracted down to the name of the infecting agent; patient no longer suffered from diseases but from micro-organisms. To the question: “what is the matter with the man in bed 4?” the answer came: “T.B.”.

But fortunately for the patient, for whom, like the soul of Faustus, the powers of good and evil were fighting, some clinicians kept their heads. But the result of the new development was that the older and cruder notions of infection had to be entirely revised; and gaps in the knowledge of metabolism had to be filled. Not only was it necessary that the clinician should think vitally and morbid-anatomically, it was necessary that he should think bacteriologically and biochemically also.

During the recent period of intensive laboratory investigation on the clinico-pathological side of diagnosis, the notion has arisen that the clinician;s observations are not really scientific, that they are of the nature of guess work, whereas everything that happens in the laboratory is controlled by the infallible rules of logic. The argument went rather like this. The test-tube and the microscope cannot lie.

But God alone knows if what the physician thinks is an enlarged spleen is the spleen; or if rose spots are not “any old spots”; or the association of a soft and infrequent pulse with a continued high fever is not some infrequent pulse with a continued high fever is not some odd trick of Nature designed to intrigue the curious minded; and why should not a week of intense headache pass away somewhat suddenly and be replaced by a muttering delirium; and an unexplained deafness appear?

Funny things like these do happen to people who suffer from the disease of microbic origin. But the one certain thing is that the disease isnt typhoid fever, or any infection on the R.A.B. group, because there is no agglutination of the laboratory stains of those organisms by the patients serum.

Strange, this idea that facts have a different value according as they are observed at the bedside or in the laboratory. Stranger still, the idea that one negative observation in the laboratory should, even by responsible clinicians, be regarded as more important than the co-existence of six positive observations at the bedside. In the words of the logician, “we can never, by a single experiment, prove the non-existence of a supposed effect”. If “science arise from the discovery of identity amidst diversity”, then it matters not if the identity be discovered by careful observation of the patient clinically or pathologically.

The whole question is, is it a true identity? But this, in the last resort, depends upon the critical judgment of the observer. Granted that the exercise of judgment at the bedside is more difficult than it is in the laboratory, mistakes in judgment are not confined to the bedside. We have only to send a specimen of the same stool to two, or even to six, bacteriologists, equally expert, to find that failure to “discover identity” is by no means only a beside difficulty. Here the question of criteria is involved, as we known, and criteria are not always uniform even amongst laboratory workers. Their results are, therefore, of necessity, not always comparable.

Now the clinician criteria are, in general, less exact than the pathologists, or can they be made so exact very easily; but if they are made severe, as they should be-if nothing is termed positive which is only doubtfully positive; if the clinicians judgment concerning his observation is controlled by reliable technic; if discovered identities are unequivocal-then the clinicians facts” are as scientific and as logical as are those of the pathologist. The truth is that clear- thinking, with forbearance, is essential to the satisfactory solution of a diagnostic problem whether the contribution comes from the laboratory or from the bedside.

There is a technic of the mind as well as of the eye and of the hand, and the former is quite as essential as the latter. It is not only what you find at the bedside, it is also what you bring to the bedside that matters. The eye sees what it takes with it the power seeing; in other words, it is the mind that sees. And surely it is the same words, it is the mind that sees. And surely it is the same in the laboratory?

In both spheres there comes to some-slowly, painfully, towards the end (alas!) facility born by patient practice out of time. clinician and pathologist are more akin than they sometimes realize. Each of them takes a pride (which the other regards as excessive) in his small discoveries, and each of them lacks humility (or so the other thinks) in face of the of the ward or in the laboratory, momentous things are happening under their very eyes, yet they see them not, for they are both under the same ban-they cannot live in advanced of their generation.

But clinical medicine is just now coming back into its own. The prince has taken notice of the neglected charms of our modest Cinderella. A marriage has been arranged. Professors are leading the bride to the altar, and the name of her bridegroom is Research. There is just time for me, as an interested and loving uncle, to give the pair my blessing:.

“Let me not to the marriage of true minds

Admit impediments. Love is not love

Which alters when it alteration finds,

Or bends with the remover to remove”.

And so is resumed afresh the long line of clinical observers which has been lit by the genius of Hippocrates, of Sydenham, of Trousseau, of Osler, and of many others-masters in clinical research.

II. To-day we are witnessing the apothesis of the machine in human life and it is not surprising to find that medicine, like other spheres of action, is being mechanized. The public has come to believe that machinery is revolutionizing the healing art and is dispensing with the need for human judgment. It is true that the introduction of instruments of precision into medicine has been of great service, but the interpretation of the results obtained by them in the interpretation of the results obtained by them in the individual case still demands wisdom and experience on the part of the doctor.

Where the machine is greater than the man the patient perishes. A large section of the public does not understand this. It has such an incorrigible love for love for apparatus, and what it produces, that it hailed with acclamation a box of gadgets, constructed in defiance of all scientific principles, which claimed to hand out an exact diagnosis, and even the appropriate treatment, and thus make the application of so fallible a thing as the human mind unnecessary.

Failing the reduction of medicine to machinery, the public seeks salvation in the specialist and the expert; and the more apparatus, and the more complicated, employed by these, the greater its confidence. The number of really intelligent citizens, whose health is their best asset, and yet who have no physician or general practitioner, has greatly increased of late years. In consequence of this fact, situations arise which are no only ludicrous but dangerous.

Awaking in the night with a pain in the belly the immediate anxiety is not whether he will find the physician available, but whether the right specialist will be sent for. Is it the appendix, or the gallbladder-or the stomach- or the kidney-man he needs? What if he rings up the wrong one? Perhaps the trouble isnt in his belly at all, for he suddenly remembers that what his business friend thought was a severe attack of indigestion last week turned out to be coronary thrombosis. So perhaps it is a cardiologist he needs? God! how difficult life-and especially medicine-is!.

With the growth of specialism have appeared the diagnostic clinic and group medicine. I do not propose to discuss the pros and cons of this development. Undoubtedly the group system has its advantages, but I am quite sure that unless the team, whatever name it bears, has on its panel a general clinician of experience, it cannot effect the best service for the patient. For in the process involved there are two key points, both of them vital, at which his help is essential.

There is the point at which, after a complete history of the case is obtained, and a general and thorough overhaul is made, the decision is arrived at as to what special examinations shall be undertaken; and then there is the point at which the correlation and interpretation of the results of such special examinations are considered in relation to the particular case. If there is not assessor whose duty it is to undertake these two important functions, the whole system brake down.

In regard to the first point, a sensitive and apprehensive patient may easily be made still more so by elaborate investigations, which are not really indicated, or invalids may be constructed where previously they did not exist. In regard to the second point the danger is equally great. Patients dossiers are apt, in these days, to be so full and so heterogeneous that the courage to say of some of the reports, “noted, nothing doing”, is often the first step in the elucidation of the problem.

It falls to the clinician alone to become familiar with the range of health, to be sensitive to what lies with it it, and to what lies outside it. the exercise of this sensitiveness becomes more and more essential the more meticulously exact the reports of the experts may be.

And these reports tend to be more and more meticulously exact with the increasing tendency to specialism and the myopia which goes with it. the number of patient whose hearts are healthy is in inverse proportion to the number of cardiologists they consult, and the frequency with which they are “electrocardiographed”. An upper respiratory tract which is passed as “normal” by a careful “nose and throat man” will soon be so rare as to merit demonstration at the Academy of Medicine.

Someone must preserve his poise, and if the clinician does not, no one does. Think of the stunts-in diet, in exercise, in clothes, in habits-that the patient is besought to follow in order to be saved. Think of the panaceas by way of drugs, or of operations. Think of the many adventures in numerous therapeutic fields concerning which one can only say, when all is done, that one has been witnessing the triumph of technic over reason. Think again, of the fears that are bred in the minds even of those who are well, that if they do not follow this cult, or that, they will die the death.

There are in my country, and I believe you are not free from them in yours, pernicious folk who try to plant in the public mind the idea that to preserve health is a very ticklish thing. The citizen is led to believe that only by a series of close observances, and equally close restrictions, can he hope for physical salvation. The way of health is pictured as a tightrope along which we make a slow and trepidating progress. The least bias to right or left, not immediately corrected, or corrected inaccurately, and we plunge headlong into the abyss.

Here awaits us inflammations and ulcers and cancer-especially cancer. Of the people who disseminate these ideas the worst enemies are those of our own household, because they are thought to speak with authority. It is for the general clinician to prick this kind of bubble, and to point out that health is really a broad and well-paved road and, speaking generally, and given a modicum of good fortune, the wayfaring man must be a fool indeed if he errs therein.

Again, if the physician drops out there is no one left to make real contact with the patient on the psychological side. This becomes more and more a function of the doctors as men and women taken more and more control of their lives. To-day, the difficulty facing men and women is no longer that they are cramped by authority and by convention but that they get fatigued, or even run themselves to destruction, but their new found freedom.

Realizing that the causes of their unhappiness, as of their physical ills, lie in the biological sphere, they seek the physician rather than the priest. Bewildered by the prospect which their liberty opens out to them, and all unaccustomed to deal with the raw material of their natures as it is now revealed, they not seldom mistake their emotional confusion for physical illness and they come to us for guidance. To them the doctor is the realist, the link between the “fine abstraction” which still beckons them, and the “particular application” for which they long.

The doctor is in the privileged position of the Almighty: he, and only he, has-or can have if he will-all the evidence before him. “he that sinneth before his Maker, let him fall into the hands of the physician.” Why? Because to the physician the individual is not a metaphysical-constant but a physical variable and this outlook enables him lift up the weary head and to comfort the sorrowing heart. First the explanation, then the guidance, and hope, the best of tonics, is reborn.

To be a little more concrete may I remind you that patients go in and out of our consulting rooms, and pass through clinics and groups, with the salient points of their cases undiscovered because they are handled as bundle of organs and functions and not as human beings. One such case in illustration. A short time ago I was asked to examine a woman who had been put to bed on the advice of a cardiologist. Half of the estimated six weeks had passed and my permission was sought to waive the other half on the ground that she seemed so well.

I examined her and found no sings of disease. Puzzled, I asked if i might see her alone. When the doctor and the nurse had left the room the patient said, “You havent found anything the mater with me, have you, doctor?” “No,” I replied. “I didnt think you would,” said the patient. “But why are like this. I am very attached to my husband and I suddenly discovered he was keeping another establishment.

The shock was terrible, and I got no sleep for three nights. Then I looked so ill that my husband insisted upon sending for the doctor. He found my pulse was very quick so he sent me to a heart specialist. After his examination he advised me to go to bed for six weeks.” “But why didnt you tell him what had caused your palpitation?” I asked. ” tried to,” said the patient, “I tried to tell him twice, but each time he put his hand up and said Dont interrupt me, please, I am making my observations.

You may be saying to yourselves at this point, or long before it, “but all this boils down to a plea for the maintenance of the family physician, the general practitioner, that is.” Very good; that is what I am saying, that and some other things. This because I see a gradual, that and some other things. This because I see a gradual, but definite tendency to eliminate the physician that I advance many of these points.

The spread of specialism and the increased interest of the public in medical matters have both of them combined to narrow the function of the general practitioner, who is, or who should be, the clinician pax excellence, almost to the vanishing point. I regard this as being no less dangerous to the public than it would be for the passengers of the ship if the captain left the bridge and the chief engineer, or the chief steward, or the radio operator, took his place. But I see the equivalent of this being done day after day.

Whereas formerly, the physician kept control of the case and exercise his judgment in deciding the program of treatment,he now, all too often, stands aside and allows his specialist colleagues to take charge, over the shoulders of whom, as it were, he gets an occasional and momentary glance of his patient. Or-and this experience becomes more and more frequent-he isnt there at all. The specialist is there from the first, one, or a number, for it is not uncommon to see a patient being treated by a committee, just as though he were a banking concern, run by a board of directors; only the patient is in a worse plight, because even a back has its manager.

But the trouble is not alone on account of the growth of specialism and the gregariousness of the public. “The fault is in ourselves that we are underlings”.

To tell the truth, we are afraid of simplicity, and yet it is simplicity, with a dash of courage and independence. We are scared stiff, if the fact be known, lest, whilst we slept last night, or whilst we took out brief holiday, some great advance may have taken place in medicine of which we are unaware. But we neednt worry, for science, like nature, never proceeds by leaps.

Besides, we shall hear all about it soon enough, either from the chemists traveller or from our patients, or from the headlines in the daily press. In other words, that lag, which is often called conservation, and for which we are so often censured, is an extremely useful asset in the doctors mental equipment. For nature is herself conservative, and yields little or nothing to our hustling.

Rt. Hon. Lord Horder