At a medical conference last week, I learned of a patient with a very complex illness. He had been seen by nine consultants, none of whom had actually touched him. The 10th consultant sat at the bedside and listened carefully to the man before examining him. This led to a rational plan of analysis and treatment of his life-threatening disorder.
Listening and seeing with deliberation are ancient diagnostic tools at risk of being forgotten in an era of high-tech medicine.
I thought of the man with many doctors as I reflected upon the career of Dr. Winston Caine, who died last week.
I met Winston in medical school in Baltimore in 1961. Subsequently, we shared years on the medical house staff at Vanderbilt Hospital in Nashville. After separate stints of military service, we were members of a medical partnership for 33 years.
At the outset of a shared journey, technology was in its infancy. Medications for high blood pressure, diabetes and many infectious diseases were limited and often associated with unpleasant and, sometimes, dangerous side effects. Cancer chemotherapy was in a crude infancy. In a breakthrough, an electrical engineer and a heart surgeon collaborated to produce the first heart defibrillator. CAT scans, MRIs and systems of life support remained on a distant horizon.
While we were at Vanderbilt, kidney dialysis began. A four-bed intensive care unit opened. Research provided new treatment options for leukemia, heart disease and organ transplantation. Collaborative research between pharmaceutical companies and academic labs led to a rapidly expanding menu of medications for almost all illnesses. HIV/AIDS exploded on the scene in the 1980s to remind us of our vulnerabilities to new, epidemic diseases.
New technologies were introduced faster than we could comprehend how to employ them most efficiently. Associated costs skyrocketed. Medical ethics struggled to keep up with all the new choices in therapy. Harmon Smith, a distinguished professor of ethics at Duke, summarized the dilemma with a question: "Who gets how much of what, when there is not enough to go around?" We have yet to answer this inquiry.
Winston chose the field of hematology for specialty training and practice. Leukemias and lymphomas, malignant diseases involving lymph nodes and related tissues, fall within this branch of medicine. When Winston began his work in this discipline, treatment was often limited, and many patients died.
Hodgkin's disease, one of the lymphomas, carried with it a bleak outlook. Near the end of our Vanderbilt years, a new therapy involving high-dose radiation offered fresh hope for victims of the disease. Subsequently, we learned that the radiation could severely damage other organs, such as the heart. Expanding options of chemotherapy presented double-edged swords of benefit and risk of side effects, sometimes the generation of new malignancies.
Basic scientists progressively informed clinicians of the biology of malignant cells in bone marrow and lymph nodes. Treatment became more precise. Rates of remission and cure steadily rose. New insights into the DNA of malignant cells point to even more individualized treatment for people who suffer from these diseases.
To keep abreast of changes in therapy, Winston exemplified the clinical scholar: reading, directing and attending seminars, always alert to something that would offer hope to his patients. He exemplified the clinical teacher, sharing this complex information with medical students and residents whom he cherished as colleagues.
A disease, whether acute leukemia or Hodgkin's disease, occurs in a unique human being, a person whose aspirations, relationships and identity are suddenly placed in unexpected jeopardy. And this is a basic premise of clinical medicine that Winston Caine never forgot.
He listened soulfully to learn of the person who had the illness. He examined meticulously the person and then her diagnostic data. He did not hesitate to involve local or regional experts if he had uncertainties as to how best to restore health to this individual. Years on high school and college football teams had ingrained in him the value of teamwork.
He quietly celebrated success in battles against disease. He comforted the dying and their loved ones when disease could not be conquered.
The proper practice of medicine is deeply personal. It is focused, respectful, tireless and, above all, compassionate. I celebrate Winston P. Caine Jr., physician.
Email Clif Cleaveland at firstname.lastname@example.org.
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