The Youngest Science

by Lewis Thomas

  Doctor, medicine, and physician, taken together with the cognate words that grew up around them, tell us a great deal about society’s ancient expectations from the profession, hard to live up to. Of all the list, moderate and modest seem to me the ones most in need of remembering. The root med has tucked itself inside these words, living as a successful symbiont, and its similar existence all these years inside medicine should be a steady message for the teacher, the healer, the collector of science, the old leech.

  Medicine was once the most respected of all the professions. Today, when it possesses an array of technologies for treating (or curing) diseases which were simply beyond comprehension a few years ago, medicine is under attack for all sorts of reasons. Doctors, the critics say, are applied scientists, concerned only with the disease at hand but never with the patient as an individual, whole person. They do not really listen. They are unwilling or incapable of explaining things to sick people or their families. They make mistakes in their risky technologies; hence the rapidly escalating cost of malpractice insurance. They are accessible only in their offices in huge, alarming clinics or within the walls of terrifying hospitals. The word “dehumanizing” is used as an epithet for the way they are trained, and for the way they practice. The old art of medicine has been lost, forgotten.

  The American medical schools are under pressure from all sides to bring back the family doctor—the sagacious, avuncular physician who used to make house calls, look after the illnesses of every member of the family, was even able to call the family dog by name. Whole new academic departments have been installed—some of them, in the state-run medical schools, actually legislated into existence—called, in the official catalogues, Family Practice, Primary Health Care, Preventive Medicine, Primary Medicine. The avowed intention is to turn out more general practitioners of the type that everyone remembers from childhood or from one’s parents’ or grandparents’ childhood, or from books, movies, and television.

  What is it that people have always expected from the doctor? How, indeed, has the profession of medicine survived for so much of human history? Doctors as a class have always been criticized for their deficiencies. Montaigne in his time, Molière in his, and Shaw had less regard for doctors and their medicine than today’s critics. What on earth were the patients of physicians in the nineteenth century and the centuries before, all the way back to my professional ancestors, the shamans of prehistory, hoping for when they called for the doctor? In the years of the great plagues, when carts came through the town streets each night to pick up the dead and carry them off for burial, what was the function of the doctor? Bubonic plague, typhus, tuberculosis, and syphilis were representative examples of a great number of rapidly progressive and usually lethal infections, killing off most of the victims no matter what was done by the doctor. What did the man do, when called out at night to visit the sick for whom he had nothing to offer for palliation, much less cure?

  Well, one thing he did, early on in history, was plainly magic. The shaman learned his profession the hardest way: he was compelled to go through something like a version of death itself, personally, and when he emerged he was considered qualified to deal with patients. He had epileptic fits, saw visions, and heard voices, lost himself in the wilderness for weeks on end, fell into long stretches of coma, and when he came back to life he was licensed to practice, dancing around the bedside, making smoke, chanting incomprehensibilities, and touching the patient everywhere. The touching was the real professional secret, never acknowledged as the central, essential skill, always obscured by the dancing and the chanting, but always busily there, the laying on of hands.

  There, I think, is the oldest and most effective act of doctors, the touching. Some people don’t like being handled by others, but not, or almost never, sick people. They need being touched, and part of the dismay in being very sick is the lack of close human contact. Ordinary people, even close friends, even family members, tend to stay away from the very sick, touching them as infrequently as possible for fear of interfering, or catching the illness, or just for fear of bad luck. The doctor’s oldest skill in trade was to place his hands on the patient.

  Over the centuries, the skill became more specialized and refined, the hands learned other things to do beyond mere contact. They probed to feel the pulse at the wrist, the tip of the spleen, or the edge of the liver, thumped to elicit resonant or dull sounds over the lungs, spread ointments over the skin, nicked veins for bleeding, but at the same time touched, caressed, and at the end held on to the patient’s fingers.

  Most of the men who practiced this laying on of hands must have possessed, to begin with, the gift of affection. There are, certainly, some people who do not like other people much, and they would have been likely to stay away from an occupation requiring touching. If, by mistake, they found themselves apprenticed for medicine, they probably backed off or, if not, turned into unsuccessful doctors.

  Touching with the naked ear was one of the great advances in the history of medicine. Once it was learned that the heart and lungs made sounds of their own, and that the sounds were sometimes useful for diagnosis, physicians placed an ear over the heart, and over areas on the front and back of the chest, and listened. It is hard to imagine a friendlier human gesture, a more intimate signal of personal concern and affection, than these close bowed heads affixed to the skin. The stethoscope was invented in the nineteenth century, vastly enhancing the acoustics of the thorax, but removing the physician a certain distance from his patient. It was the earliest device of many still to come, one new technology after another, designed to increase that distance.

  Today, the doctor can perform a great many of his most essential tasks from his office in another building without ever seeing the patient. There are even computer programs for the taking of a history: a clerk can ask the questions and check the boxes on a printed form, and the computer will instantly provide a printout of the diagnostic possibilities to be considered and the laboratory procedures to be undertaken. Instead of spending forty-five minutes listening to the chest and palpating the abdomen, the doctor can sign a slip which sends the patient off to the X-ray department for a CT scan, with the expectation of seeing within the hour, in exquisite detail, all the body’s internal organs which he formerly had to make guesses about with his fingers and ears. The biochemistry laboratory eliminates the need for pondering and waiting for the appearance of new signs and symptoms. Computerized devices reveal electronic intimacies of the flawed heart or malfunctioning brain with a precision far beyond the touch or reach, or even the imagining, of the physician at the bedside a few generations back.

  The doctor can set himself, if he likes, at a distance, remote from the patient and the family, never touching anyone beyond a perfunctory handshake as the first and only contact. Medicine is no longer the laying on of hands, it is more like the reading of signals from machines.

  The mechanization of scientific medicine is here to stay. The new medicine works. It is a vastly more complicated profession, with more things to be done on short notice on which issues of life or death depend. The physician has the same obligations that he carried, overworked and often despairingly, fifty years ago, but now with any number of technological maneuvers to be undertaken quickly and with precision. It looks to the patient like a different experience from what his parents told him about, with something important left out. The doctor seems less like the close friend and confidant, less interested in him as a person, wholly concerned with treating the disease. And there is no changing this, no going back; nor, when you think about it, is there really any reason for wanting to go back. If I develop the signs and symptoms of malignant hypertension, or cancer of the colon, or subacute bacterial endocarditis, I want as much comfort and friendship as I can find at hand, but mostly I want to be treated quickly and effectively so as to survive, if that is possible. If I am in bed in a modern hospital, worrying about the cost of that bed as well, I want to get out
as fast as possible, whole if possible.

  In my father’s time, talking with the patient was the biggest part of medicine, for it was almost all there was to do. The doctor–patient relationship was, for better or worse, a long conversation in which the patient was at the epicenter of concern and knew it. When I was an intern and scientific technology was in its earliest stage, the talk was still there, but hurried, often on the run.

  Today, with the advance of medicine’s various and complicated new technologies, the ward rounds now at the foot of the bed, the drawing of blood samples for automated assessment of every known (or suggested) biochemical abnormality, the rolling of wheelchairs and litters down through the corridors to the X-ray department, there is less time for talking. The longest and most personal conversations held with hospital patients when they come to the hospital are discussions of finances and insurance, engaged in by personnel trained in accountancy, whose scientific instruments are the computers. The hospitalized patient feels, for a time, like a working part of an immense, automated apparatus. He is admitted and discharged by batteries of computers, sometimes without even learning the doctors’ names. The difference can be strange and vaguely dismaying for patients. But there is another difference, worth emphasis. Many patients go home speedily, in good health, cured of their diseases. In my father’s day this happened much less often, and when it did, it was a matter of good luck or a strong constitution. When it happens today, it is more frequently due to technology.

  There are costs to be faced. Not just money, the real and heavy dollar costs. The close-up, reassuring, warm touch of the physician, the comfort and concern, the long, leisurely discussions in which everything including the dog can be worked into the conversation, are disappearing from the practice of medicine, and this may turn out to be too great a loss for the doctor as well as for the patient. This uniquely subtle, personal relationship has roots that go back into the beginnings of medicine’s history, and needs preserving. To do it right has never been easy; it takes the best of doctors, the best of friends. Once lost, even for as short a time as one generation, it may be too difficult a task to bring it back again.

  If I were a medical student or an intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be trying to figure out ways to keep this from happening.

  7

  NURSES

  When my mother became a registered nurse at Roosevelt Hospital, in 1903, there was no question in anyone’s mind about what nurses did as professionals. They did what the doctors ordered. The attending physician would arrive for his ward rounds in the early morning, and when he arrived at the ward office the head nurse would be waiting for him, ready to take his hat and coat, and his cane, and she would stand while he had his cup of tea before starting. Entering the ward, she would hold the door for him to go first, then his entourage of interns and medical students, then she followed. At each bedside, after he had conducted his examination and reviewed the patient’s progress, he would tell the nurse what needed doing that day, and she would write it down on the part of the chart reserved for nursing notes. An hour or two later he would be gone from the ward, and the work of the rest of the day and the night to follow was the nurse’s frenetic occupation. In addition to the stipulated orders, she had an endless list of routine things to do, all learned in her two years of nursing school: the beds had to be changed and made up with fresh sheets by an exact geometric design of folding and tucking impossible for anyone but a trained nurse; the patients had to be washed head to foot; bedpans had to be brought, used, emptied, and washed; temperatures had to be taken every four hours and meticulously recorded on the chart; enemas were to be given; urine and stool samples collected, labeled, and sent off to the laboratory; throughout the day and night, medications of all sorts, usually pills and various vegetable extracts and tinctures, had to be carried on trays from bed to bed. At most times of the year about half of the forty or so patients on the ward had typhoid fever, which meant that the nurse couldn’t simply move from bed to bed in the performance of her duties; each typhoid case was screened from the other patients, and the nurse was required to put on a new gown and wash her hands in disinfectant before approaching the bedside. Patients with high fevers were sponged with cold alcohol at frequent intervals. The late-evening back rub was the rite of passage into sleep.

  In addition to the routine, workaday schedule, the nurse was responsible for responding to all calls from the patients, and it was expected that she would do so on the run. Her rounds, scheduled as methodical progressions around the ward, were continually interrupted by these calls. It was up to her to evaluate each situation quickly: a sudden abdominal pain in a typhoid patient might signify intestinal perforation; the abrupt onset of weakness, thirst, and pallor meant intestinal hemorrhage; the coughing up of gross blood by a tuberculous patient was an emergency. Some of the calls came from neighboring patients on the way to recovery; patients on open wards always kept a close eye on each other: the man in the next bed might slip into coma or seem to be dying, or be indeed dead. For such emergencies the nurse had to get word immediately to the doctor on call, usually the intern assigned to the ward, who might be off in the outpatient department or working in the diagnostic laboratory (interns of that day did all the laboratory work themselves; technicians had not yet been invented) or in his room. Nurses were not allowed to give injections or to do such emergency procedures as spinal punctures or chest taps, but they were expected to know when such maneuvers were indicated and to be ready with appropriate trays of instruments when the intern arrived on the ward.

  It was an exhausting business, but by my mother’s accounts it was the most satisfying and rewarding kind of work. As a nurse she was a low person in the professional hierarchy, always running from place to place on orders from the doctors, subject as well to strict discipline from her own administrative superiors on the nursing staff, but none of this came through in her recollections. What she remembered was her usefulness.

  Whenever my father talked to me about nurses and their work, he spoke with high regard for them as professionals. Although it was clear in his view that the task of the nurses was to do what the doctor told them to, it was also clear that he admired them for being able to do a lot of things he couldn’t possibly do, had never been trained to do. On his own rounds later on, when he became an attending physician himself, he consulted the ward nurse for her opinion about problem cases and paid careful attention to her observations and chart notes. In his own days of intern training (perhaps partly under my mother’s strong influence, I don’t know) he developed a deep and lasting respect for the whole nursing profession.

  I have spent all of my professional career in close association with, and close dependency on, nurses, and like many of my faculty colleagues, I’ve done a lot of worrying about the relationship between medicine and nursing. During most of this century the nursing profession has been having a hard time of it. It has been largely, although not entirely, an occupation for women, and sensitive issues of professional status, complicated by the special issue of the changing role of women in modern society, have led to a standoffish, often adversarial relationship between nurses and doctors. Already swamped by an increasing load of routine duties, nurses have been obliged to take on more and more purely administrative tasks: keeping the records in order; making sure the supplies are on hand for every sort of ward emergency; supervising the activities of the new paraprofessional group called LPNs (licensed practical nurses), who now perform much of the bedside work once done by RNs (registered nurses); overseeing ward maids, porters, and cleaners; seeing to it that patients scheduled for X rays are on their way to the X-ray department on time. Therefore, they have to spend more of their time at desks in the ward office and less time at the be
dsides. Too late maybe, the nurses have begun to realize that they are gradually being excluded from the one duty which had previously been their most important reward but which had been so taken for granted that nobody mentioned it in listing the duties of a nurse: close personal contact with patients. Along with everything else nurses did in the long day’s work, making up for all the tough and sometimes demeaning jobs assigned to them, they had the matchless opportunity to be useful friends to great numbers of human beings in trouble. They listened to their patients all day long and through the night, they gave comfort and reassurance to the patients and their families, they got to know them as friends, they were depended on. To contemplate the loss of this part of their work has been the deepest worry for nurses at large, and for the faculties responsible for the curricula of the nation’s new and expanding nursing schools. The issue lies at the center of the running argument between medical school and nursing school administrators, but it is never clearly stated. Nursing education has been upgraded in recent years. Almost all the former hospital schools, which took in high-school graduates and provided an RN certificate after two or three years, have been replaced by schools attached to colleges and universities, with a four-year curriculum leading simultaneously to a bachelor’s degree and an RN certificate.

  The doctors worry that nurses are trying to move away from their historical responsibilities to medicine (meaning, really, to the doctors’ orders). The nurses assert that they are their own profession, responsible for their own standards, coequal colleagues with physicians, and they do not wish to become mere ward administrators or technicians (although some of them, carrying the new and prestigious title of “nurse practitioner,” are being trained within nursing schools to perform some of the most complex technological responsibilities in hospital emergency rooms and intensive care units). The doctors claim that what the nurses really want is to become substitute psychiatrists. The nurses reply that they have unavoidable responsibilities for the mental health and well-being of their patients, and that these are different from the doctors’ tasks. Eventually the arguments will work themselves out, and some sort of agreement will be reached, but if it is to be settled intelligently, some way will have to be found to preserve and strengthen the traditional and highly personal nurse-patient relationship.