Surgeon and writer Sherwin B. Nuland, MD, begins his book of short essays, The Uncertain Art: Thoughts on A Life in Medicine, with a meditation on Hippocrates' First Aphorism: “Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgment difficult.”
Even for physicians in 400 BCE, Nuland notes, “no man's lifetime was sufficient to learn all that was required.” Despite enormous scientific progress, he argues, medicine will never be a pure science because physicians and patients are human. Timely recognition and diagnosis of disease is crucial, yet things are not always what they seem, and clinical decisions must be made with “incomplete and largely ambiguous information.” Results of controlled trials may be hard to apply to an individual patient. Becoming “comfortable with uncertainty,” Nuland contends, “is one of the primary goals in the training of a physician.” Paradoxically, he points out, much of the intellectual challenge of medicine comes from uncertainty as well.
Nuland's many books include How We Die: Reflections on Life's Final Chapter, which won a National Book Award; How We Live; The Wisdom of the Body; Medicine: the Art of Healing; Doctors: the History of Scientific Medicine; Maimonides (Jewish Encounters); and The Mysteries Within: A Surgeon Explores Myth, Medicine, and the Human Body. He has contributed to The New Yorker, The New Republic, The New York Review of Books, The New York Times and Time magazine.
These essays were originally published between 1998 and 2004 in The American Scholar, the journal of the Phi Beta Kappa Society. Nuland writes for an educated but non-professional audience “as a doctor, about issues associated with doctoring,” exploring some of the curiosities of medicine, which was once termed the Art.
So enamored has medical education become with science, Nuland laments, that there is little time for students to learn to care for “the whole person, not just his pathology.” Given the avalanche of biomedical information, better integration of history, philosophy, ethics and literature into the medical education is an uphill struggle. Nuland, now 78, teaches clinical medicine and bioethics at Yale, and worries that academic medicine produces “excellent doctor-technicians but imperfect healers.”
The second sentence of Hippocrates' First Aphorism declares that “the physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals, cooperate.” Here Nuland ponders the quandary of the noncompliant patient (we no longer say insubordinate or recalcitrant) and the tension between individual freedom and the demands of public health.
Many essays are tales from the history of medicine, one of Nuland's passions. For instance, the doctrine of the humors underlies the adjectives bilious, phlegmatic, and melancholic. Learn why, in a fit of choler, we vent our spleen.
What four landmark works best illustrate the progress of scientific medicine? Nuland's first choice is Vesalius' illustrated human anatomy, De humani corporis fabrica, published in 1543. Direct observation challenged a millennium of received wisdom. William Harvey's On the Motion of the Heart and Blood in Animals, published in 1628, was a seminal work in physiology based on inductive reasoning and experiment. Giovanni Morgagni's three-volume work Seats and Causes of Diseases Investigated by Anatomy, published in 1761, correlated disease with physical abnormalities in tissue and stressed that “inner pathologies might be detected by taking a history or examining a patient.” The 19th century is the last, Nuland notes, where books rather than journal articles were most influential, but his choice of Gray's Anatomy, despite its staying power as a text, is rather puzzling.
Neurology is sadly absent. Thomas Willis, working at the same time as Harvey, established the brain as the seat of intelligence, correlating anatomy and clinical symptoms. Hughlings Jackson, S. Weir Mitchell, Charcot and a host of 19th century neurologists are nowhere mentioned.
How personalities influence medical progress is another favorite theme. Vesalius — ambitious, inquisitive and impatient with authority — did more than advance the study of anatomy: he presumed to correct the doctrines of Galen. Ignac Semmelweis theorized that childbed fever was caused by “invisible organic matter” carried on doctors' hands from the autopsy room to the patient, but he was haughty, antagonistic, and ignored by his colleagues. Decades later, Joseph Lister's patient demonstrations and lower operative mortality finally convinced surgeons of the value of cleanliness and carbolic acid.
Taking a fresh look at Thomas Eakins' famous painting, “The Gross Clinic,” Nuland makes the case that Eakins was critical rather than laudatory of famous Philadelphia surgeon Samuel Gross, who was an opponent of Lister's antisepsis. Eakins was a keen student of anatomy and portrays Gross barehanded, in street clothes, surrounded by non-sterile instruments.
Robbing graves to obtain cadavers for anatomic study is a skeleton in the Art's closet that Nuland recounts in horrific, entertaining detail. “Scatological Medicine” explores human preoccupation with constipation from the Egyptians, who invented the enema, to the early 20th century misapplication of the germ theory of disease as “autointoxication.”
Nuland is also intrigued by phenomena that defy Western medical explanation: acupuncture anesthesia, which he saw employed in China; the placebo effect; and electroconvulsive therapy. He does not mention in his essay that he underwent ECT himself in the 1970s to overcome a depression that nearly wrecked his career. A link from his Wikipedia biography leads to a short video, released publicly in 2007, of a 2001 lecture at the TED (Technology Entertainment Design) conference describing his experience. He is as engaging a speaker as he is a writer, and his talk ties together many themes in his work.
Musings on the joys of exercise, the dreaded call, “Is there a doctor in the house,” his approach to writing and speculations on the future of medicine were less compelling. The final essay honors a heart transplant candidate whom he befriended, and hoped to write about, using the patient's letters to describe the emotional rollercoaster of his illness. Readers, like Nuland, will hope for the best and mourn the limitations of the Art.
For Nuland the practice of medicine has been the “key to understanding the way we live” and a way to “search for the reality of the human condition.” The Uncertain Art makes for thoughtful leisure reading and would make a fine gift. It could lead you back to Hippocrates, to Nuland's other books, and to better integration of the humanities in your own continuing medical education.
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FOR MORE ON THE VACCINE- AUTISM ASSOCIATION
Background about the cases involving the National Vaccine Injury Compensation Program — and the entire text of the decisions for the first three test cases — are available online: www.uscfc.uscourts.gov/node/5026.
- The American Academy of Pediatrics Childhood Immunization Support Program: www.cispimmunize.org.
- “Immunization Safety Review: Vaccines and Autism,” Institute of Medicine, May 17, 2004: www.iom.edu/CMS/3793/4705/20155.aspx.
- The Institute for Vaccine Safety: www.vaccinesafety.edu.
- The Children's Hospital of Philadelphia Vaccine Education Center: www.chop.edu/consumer/jsp/microsite/microsite.jsp?id=75918.
- Visit www.neurotodayonline.com for these articles: “After Vaccine-Autism Case Settlement, MDs Urged to Continue Recommending Vaccines,” June 5, 2008; “Federal Vaccine Court Opens Controversial Autism Proceedings,” July 3, 2007.
AAN PROPOSED SLATE OF OFFICERS
The Nominations Committee, chaired by Sandra F. Olson, MD, FAAN, is pleased to present the membership with the following proposed slate of officers for the 2009–;2011 term. Please plan to attend the business meeting in Seattle on Tuesday, April 28, 2009, when a vote will be held. If you have any questions, contact Donna Honeyman at email@example.com or 651-695-2713.
2009-2011 AAN/AANPA Board of Directors Proposed Slate of Officers
President: Robert C. Griggs, MD, FAAN
President Elect: Bruce Sigsbee, MD, FAAN
Vice President: Edgar J. Kenton, MD, FAAN
Secretary: Lisa M. Shulman, MD, FAAN
Treasurer: Terrence L. Cascino, MD, FAAN
Stephen M. Sergay, MB BCh, FAAN
Robert Baumann, MD, FAAN
Susan B. Bressman, MD, FAAN
Vinay Chaudhry, MD, FAAN
Ralph Jozefowicz, MD, FAAN
Aaron Miller, MD, FAAN
Timothy A. Pedley, MD, FAAN
Laura B. Powers, MD, FAAN
Karen Roos, MD, FAAN
Mark S. Yerby, MD, FAAN
Journal Editor-in-Chief John Noseworthy, MD, FAAN
Chair, AAN Foundation
Austin J. Sumner, MD, FAAN
Chair, AAN Enterprises Inc.
Steven P. Ringel, MD, FAAN
Catherine M. Rydell