published Thursday, June 4th, 2009

Cleaveland: Saying farewell to textbooks

Dr. Clif Cleaveland

Commentary

Because of special relationships I have with books, I am reluctant to part company with them. The creaks from overloaded bookshelves told me such a moment was at hand. It was time to send old medical textbooks to the library’s used book sale.

At least one textbook, a copy of Grey’s Anatomy, had served as a booster seat for each of our sons as they graduated from a high chair. Some of its pages are still cemented by spilled food from long ago. I kept it.

I browsed my medical and pediatric textbooks before their departure. Advances in diagnosis and treatment since their publication half a century ago are astonishing. Polio was still a concern then in the first years after the release of the Salk vaccine. Devastating diseases such as HIV-AIDS would not be described for years. Hepatitis was described simply as “viral hepatitis” with no subdivision into A, B and C types, each with its particular characteristics.

Antibiotics were limited. Penicillin, streptomycin, erythromycin and tetracycline were mainstays for treatment of bacterial diseases. Another widely used antibiotic, chloramphenicol, raised suspicions that it injured bone marrow. We had limited insight into the looming problems of antibiotic resistance that dog us today.

For heart and circulatory disease we had a modest list of medications: digitalis, diuretics, nitroglycerin, and a pair of blood pressure medications that are no longer used. I recall a time at Vanderbilt Hospital in 1964 when we anxiously awaited the air delivery of a brandnew blood pressure medication, Aldomet, to treat a young woman with severe high blood pressure.

Arteriograms could be performed. Angioplasties could not. CT and MRI scans were years away.

Reflecting upon those years recently with a friend of internship days, we recalled several older physicians of that time. At first, as young practitioners in most fields tend to do, we assumed that we knew far more and that we were more up-todate than our older mentors could ever hope to be. But on closer observation, we noticed that each seemed to have a personal bond with their patients. These physicians sat at bedsides. After review of medical issues, they might talk briefly about a shared interest such as fishing.

The doctors seemed to know about their patients’ families and businesses. We were seeing the proper practice of the art of medicine, the humane side of a technical discipline.

In a lecture, first published in 1927 as “The Care of the Patient,” noted physician Francis W. Peabody stated, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

This personal, humane aspect of medical care is in jeopardy as the technology of medicine rapidly advances. Electronic medical records, for example, permit standardization and sharing of patients’ files. They cannot substitute for eye contact and a sympathetic ear when a frightened patient seeks help. Dr. Peabody further wrote, “The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.”

Because of the increased specialization of medical practice, a patient is at risk of being viewed as a collection of individual organ systems, each presided over by a highly trained expert. The steady erosion of primary care means that fewer people will have a medical “home” where they are considered as complex, unique individuals with personal histories and needs. A friend recently described to me his daylong evaluation in a distinguished regional medical center: “I felt like a side of beef on a conveyor belt.”

Up-to-date, highly sophisticated medical care need not be devoid of human sympathy. The words of Dr. Peabody and the examples of the older physicians who helped shape my friend and me are timeless. The key for physicians preparing for any specialty is excellent preparation in the humanities to accompany a sound background in the sciences of medicine. Absent the artful dimension, medicine is at risk of becoming a heartless, mechanical endeavor. “A Whole New Life,” Reynolds Price’s memoir of his catastrophic illness is necessary reading for all of us who will be patients or care-givers. This powerful text reminds us that while technology may evolve, compassion does not.

E-mail Clif Cleaveland at cleaveland1000@comcast.net.

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