Chapter VII: the medical mind.

AuthorFenigsen, Richard
PositionOther People's Lives: Reflections on Medicine, Ethics, and Euthanasia

Learning Medicine From a Master. In 1997, Dr. Joseph Stanton invited me to address the students and recent graduates of Harvard Medical School who were taking the restated Hippocratic Oath. Here is what I said: (80)

Dear Friends, I want to draw your attention to a sentence in the original Oath, which reads: I will pay the same respect to my master in the Science as to my parents. It is not so much a matter of respect any more, the forms of respect change with time and I think the present-day masters like to be treated as fellow students of medicine, and of course that's what we all are. But what in my opinion is still important, and what the Oath took for granted, is learning medicine from a master.

Let me tell you a story that my teacher, Dr. Jakubowski, told me many years ago. In 1915, as a young military doctor with the Russian army during World War I, he stayed with his regiment in a provincial town in Central Russia. While there, he was called to see a very sick twelve-year old girl who was running a fever of 40[degrees] C (104[degrees] F). Two doctors had seen her and couldn't find the cause. After a meticulous routine examination, neither could Dr. Jakubowski. But he remembered a lesson from his Paris student years, something his teacher in surgery had told him: "If a child comes back from school and does not complain of anything, but the next day falls ill with high fever, tap with your finger all long bones. Children are kicked by playmates at ball games, don't pay attention to the injury, and forget about it. Meanwhile, bacteria from the child's throat or teeth may settle in the injured bone and osteomyelitis develops." (81)

Dr. Jakubowski percussed the girl's bones inch by inch and found a very painful spot in the left shin. Within hours the surgeon at the local hospital chiseled out the infected piece of bone, and the child was cured. Tearful parents came to thank Dr. Jakubowski, and the father said: "Bob vas poslal" ("God has sent you"). Agnostic as he was, Jakubowski must have been moved by these words because I could see that even forty years after the event he had to subdue some emotion while telling this part of the story.

Since the day I heard it, I have inquired about possible trauma and percussed the bones in every case of unexplained fever. It paid off two years later, in a quite exceptional, I would even say, unheard of case. A distant relative of mine, Mr. S, was rushed 150 miles to my hospital in Lodz, Poland, with a fever of 103[degrees]-104[degrees] E He had been doing some repairs and fell from the roof of his house. He didn't break any bones and hurt nowhere, but two days after the fall the fever began.

Percussing his bones, I found in the right shin a spot that not only was painful, but there was even fluctuation indicating the presence of fluid. An area of rarefied bone was seen on the X-rays. I punctured the affected spot and drew thick green pus. The patient was transferred to the department of the excellent bone surgeon Dr. Wroblewski. Meanwhile, sensational news came from the lab: the pus swarmed with Salmonella typhi, the causative agent of typhoid fever!

The patient had typhoid fever during World War II. It turned out that he still was a carrier of the bacilli, stored in his gall bladder. Bone surgery had to be combined with a chloramphenicol cure.

About a year later, at a military hospital in Lodz, I saw a pale, sick lady of 34. She ran a hectic fever that alternated with profuse sweating. The patient's left forearm was swollen, and her spleen was palpable, soft on touch. Her white blood cell count was elevated to 32,000. It had been four days since her admission and she didn't have a diagnosis. The head of the department, Dr. H, a laboratory-minded theorist who was out of touch with clinical practice, never once examined the patient, but kept firing away disparate and improbable diagnoses that had no connection with the patient's problem. Carefully examining the forearm, I found fluctuation. Puncture revealed pus. I proceeded to percuss the bones, and found in the right shin the area of osteomyelitis that was the source of the patient's septicemia. In the culture of the pus from the forearm there was abundant growth of staphylococci. A sequestered piece of dead infected bone was removed by surgery, and an intensive antibiotic treatment eliminated the distant foci of infection.

I kept applying in my practice this method that was never mentioned in the textbooks, but in the following thirty years found no more cases of osteomyelitis. Indeed, my gradual, and then definitive switching from internal medicine to cardiology reduced my chances of seeing these cases. I leave it to you to judge whether the diagnostic method that my master handed down to me, and he himself had inherited from his teacher, is cost-effective enough to be recommended.

Listening to what the master says is an important part of the young physician's education. Usually the teacher will say it in connection with a patient they have just seen together, which gives his remarks a vivid, specific, and memorable quality. Moreover, the master wouldn't bother to tell you what can be found in textbooks, he will expand beyond that.

Is there anything else? Yes indeed. Textbooks, monographs, and the top medical journals contain the best established information. This is the canon of medical knowledge. It cannot encompass the infinite multitude and variety of phenomena in health and disease, nor the enormous variety of ways in which facts present themselves to our mind under varying circumstances.

The canon does not even encompass the totality of observations made by those astute nature watchers, the practicing physicians. Doctors do not publish everything they notice. As legend will have it, Gallavardin, the prominent Lyon cardiologist, never published his observation that atrial flutter (an important disturbance in heart rhythm) can be diagnosed without electrocardiogram, just by watching the quick regular pulsation of the neck veins; but he used to demonstrate this excellent diagnostic method to his students at the bedside.

Dr. Jean Lengre had traditional medical education in mind when he formulated his maxim, "Seul un medecin peut former des autres medecins" ("only a physician can make other physicians").

Learning from a master involves now outmoded attitudes and qualities: faith in the master's knowledge and wisdom, an unavoidable emotional link of admiration and gratitude, and some humility. The present-day student sets a higher value on his own dignity and independence, and on the right to critical judgment, and prefers to preserve an impersonal distance from teachers and other business acquaintances. Medicine is still being learned from masters, but, to my regret, less and less so. The results are, to put it cautiously, mixed. Old nonsense that was only taught because it was never critically examined, is being scrapped. On the other hand, many doctors of the younger generation never learn important skills.

In following in the steps of the master, one learns bedside manners, which can calm the sick and inspire confidence. And such is the bearing of a genuine clinician, that along with the distress of a sudden illness, the very arrival of the doctor brings relief, the feeling that somebody cares and assumes responsibility.

From a master one learns the most difficult art of taking history: how to be exacting and critical, how to pursue promising tracks but avoid imposing one's own ideas on the patient; how to persevere and "fight and win this duel in the best interest of the other party,"

And the important art of palpating the abdomen can only be properly learned under a master's guidance. Please do not say, "why should we waste our time on these subtleties now that a CAT-scan will show it all and more, and with more precision." It will. But please, first use the wonderful abilities of your own senses and your own mind. The knowledge of the case you will gain in this way may instantly reveal the diagnosis. If not, it will guide your further quest and tell you which tests to order as well as clarify your conclusions.

Fortuity. The famous 19th century Swiss surgeon, Dr. Emil Kocher had a patient who was being prepared for thyroid surgery. Unexpectedly, her enlarged and hyperactive thyroid gland decreased in size. At the same time, the patient's symptoms, anxiety, palpitations, and trembling, markedly decreased. Kocher wondered how this improvement was produced. He checked all circumstances in great detail, and discovered that the lady had mixed up two bottles of medicines: she smeared the infected spot on her skin with a sedative, and swallowed the solution of iodine. Kocher then tried iodine on other patients as well and so began the new and largely effective treatment for hyperthyroidism. Other therapies are now used, but the treatment with non-radioactive iodine has been beneficial to many patients for almost a century, is still used in cases of life-threatening thyroid crisis, and, moreover, has enormously helped our understanding of the function of the thyroid gland and the thyroid hormone synthesis. All this progress was triggered by a patient's mistake.

When Dr. Karel Wenckebach, later the famous cardiologist in Vienna, worked as a general...

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