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Desperately seeking science: the creation of knowledge in family practice.

Desperately Seeking Science: The Creation of Knowledge in Family Practice

They are called doorknob questions. My patient appears satisfied, or at least he has nodded in all the right places. Clothing has been regained; we've chatted about the kids. I've closed the chart, capped my pen, and stood up. No one could miss the signals. Just as I'm reaching for the doorknob, poised to make my exit (or escape), it comes: "Why am I having these headaches?" or "Did you give me something to keep me from being so tired?" or, most dreaded of all, "Can you tell me why I've lost all interest in sex?" Once again it's happened. I've mistaken termination for closure. The patient and I have missed our connection. We've been talking about somebody else, with some other set of worries. Every once in a while I can blame my patient: this is just his way of relating to the world. But most of the time I know I'm at fault. Once again, I've forgotten that knowledge is only useful to the extent that it is accessible and relevant. From my patient's viewpoint, what is relevant coincides with the underlying concerns that brought him to the office. The concerns may be subvocal; indeed, they may be subliminal. But unless I address all anxieties, the visit will be considered a failure.

How was it that I missed the mark so badly? More than likely, I spent too much time with technical explanation, too little with personal exploration. It's so much easier to stay on the surface, to pretend that my job is done when I've translated scientific understanding into everyday language. But unless I've made the effort to understand my patient, I might just as well have saved my breath and limited my instructions to "Take this, you'll feel better in a few days."

I am what is known these days as a primary health provider, a.k.a. family doctor. It is my unique and impossible task to sit at the crossroads of technology andhuman suffering, ready to guide my patients into the mysterious temple of modern medicine. Some will experience epiphany and cure, some will wander the halls without sign of salvation. It is my particular conceit that I keep the number of human sacrifices to a minimum. If I do, it is because I have learned to distinguish true knowledge from the teachings of the false prophets of objectivity and certainly. I am situated at an interface of science and the humanities; I like to think that some of the lessons I've learned may be applied to other areas of contact in our society.

I dare speak, of course, not about medical care as a whole, but just about my own particular area of interest: the office-based evaluation and treatment of noncritical illness. If I'm seriously injured in an automobile accident, I would just as soon be evaluated by an objective emergency room doctor. If I'm undergoing surgery, I prefer my surgeon to be certain of my anatomy. But in my own daily work, my patient's needs are different. With all the medical miracles reported on the evening news, it's easy to forget that most medical consultations are for self-limited conditions that are unlikely threats to life or bodily integrity. Technical expertise remains necessary, but a different way of creating knowledge is called for than that required in the treatment of trauma or critical illness. I suspect, however, that there are applications to be made to these areas from my world of family practice.

Family practice is the applied art and science of primary medical care. In patient care, the family practitioner travels through the multidimensional continuum of his discipline: vertically from biochemistry to sociology, horizontally from pathology to psychiatry, and temporally from the infant to the aged. During the journey, through the years of his and his patients' lives, the family practitioner creates and uses knowledge of many kinds. Under the influence of a scientific education, the young doctor approaches his patient as a technical problem to be solved. Knowledge is seen as the end result of a physician-controlled, stereotypical process of investigation. But to the seasoned clinician, the most interesting variety of knowledge comes not from unilateral action, but from negotiation between the physician and patient, leading to adequate enough agreement to allow them to venture upon a course of therapy. This therapeutic knowledge and its creation are inseparable; the process and product are intertwined. In fact, as the epithet implies, the creation of this knowledge is in itself a therapeutic act. The meandering pathway to therapeutic knowledge often intersects but does not coincide with the scientific method.

The patient brings certain expectations to the clinical encounter. The patient's questions are personal, and answers of personal import are desired: "What have I been feeling? Why me? What's going to happen? Can you help me?" The answers to these questions must be received, and believed, before therapeutic knowledge can be said to exist. Indeed, for the patient these answers define the successful clinical encounter. The process of creating them creates the trust necessary before the patient can agree to an actual treatment program. The patient also expects that the physician will believe in the proposed treatment program, and that that belief will be passed on to the patient.

The physician desires to satisfy the patient by attempting to fulfill these expectations. But the physician may also require that this fulfillment fit within a pre-existing framework that is in many ways irrelevant to the patient's main concerns. In twentieth-century American medicine, this framework is the biomedical model of disease, which explains disease as a direct physical dysfunction arising from identifiable physicochemical causes. This model has been used to create a system of therapy that has demonstrated its value by the many successes of modern medicine. It is the standard by which the family physician has been taught to evaluate the validity of diagnosis and therapy. Indeed, its repeated successes give it the status in modern medicine of a scientific law.

Unfortunately, as with every other scientific hypothesis that has ever had the label "law" bestowed upon it, the biomedical model is not a fact, but only a useful approximation of reality. The contemplative physician doubts that single causes are identifiable, knows that quasi-physical (psychic) and nonphysical (social) causes exist, and sometimes suspects that even the concept of cause and effect may be called into question. I (and my patients) would be lost without a scientific basis for our decisions, but in the end, science can do no more than blaze the trail. During the creation of therapeutic knowledge, the patient typically fails to ask: "How closely do the diagnosis and proposed treatment correspond to reality?" The unvoiced "Should I believe you?" is as close as the average patient comes. If the creation of therapeutic knowledge is fully successful, then, even if the treatment fails, both physician and patient will likely choose to seek the explanation of failure elsewhere--in compliance for the physician and in fate for the patient.

Other models of disease, from chiropractic to iridology, are similarly structured though mutually exclusive. Their popularity further attests to the apparent irrelevance of the biomedical model to the patient's self-perceived interests. Practitioners in these fields fully understand the importance of therapeutic knowledge. It is always interesting to read of the arrest of another small-town fraudulent M.D. for practicing medicine without a license. I have yet to hear of a case in which the populace did not rally to his support. Despite a lack of formal training, the "doc" had been curing by listening to his patients. Popular, however, does not necessarily translate into safe and reliable. I may criticize aspects of conventional science and its biomedical model in hopes of expanding their effectiveness; I have no intention of seeking their replacements in myth or pseudoscience.

How are the different requirements of patient and physician fulfilled by the creation of therapeutic knowledge? To answer this question, it is worth examining the events within a typical office visit. It might be instructive to pick a visit for a cold for our example. Colds are a mind-numbing proposition for most physicians; the average third-year medical student only needs to see a few patients with colds before deciding to seek a career in a surgical subspecialty. My relationship with colds is far more complex. Here's an illness that is the financial lifeblood of my practice: I see thousands yearly. There are few diagnostic thrills or therapeutic triumphs to be found, but there are plenty of opportunities to alienate a patient permanently. I even have the opportunity to experience the illness personally several times a year. This keeps my empathy intact, and perhaps sharpens my diagnostic acumen. For, of course, colds do not exist. Instead, there are conjunctivitis, otitis, rhinitis, sinusitis, pharyngitis, laryngitis, tracheitis, and bronchitis, each with multiple possible etiologies. No romance here. There is, however, adequate intellectual challenge if I possess the energy to accept it on a daily basis. Every family doctor must somehow learn to study colds with a taxonomic fervor, or else be forever sentenced to a life of tedium.

As soon as I've seen the patient's chief complaint of "cold" written on the chart, and chatted about the weather or the news, I have a fairly clear idea of how the rest of the visit will proceed. Without consciously contemplating the issue, I have formed certain tentative conclusions about her illness. I know whether or not she is seriously ill, worried, or has something else of more importance to her that really brought her in today. I may very well be able to guess which treatment I will be choosing. This is not really an intuitive process; rather, experience and analysis are simply compressed to the point that the process is automatic. As the visit proceeds, I will test my conclusions against the patient's reality--this is the scientific method in action.

A process of exploration has started that I will continue to fine tune as long as I practice medicine. During this brief visit, I will alternate between apparently intuitive and explicitly formalistic modes of creating knowledge. Out of habit or experience, I generally operate as an informal epistemologist. I know some rules, and I know that some other rules exist, but I typically cruise on automatic through the patient's visit. If I stop to think about the structures I use to create knowledge, the likely result will be criticism of their validity. This sort of internal questioning is better saved for the essay than for the examining room. The physician is a natural skeptic, but this habit of mind is not particularly endearing to the suffering patient.

I begin my formal evaluation by eliciting my patient's specific symptoms, especially their temporal arrangement. I need to provide the order that we will require to reach therapeutic knowledge. Just as important, I need to know why she came to the office today. Is she worried about how bad she feels, about being contagious, about missing work, about getting worse, or about getting her voice back in time for her choir performance? I know she is going to recover from this illness whatever I decide to do; I need to know what will best help her cope with its unpleasantness while we are waiting it out. In addition, I've got my own agenda: I must do no harm, I hope to make her feel better both physically and emotionally, I want her to feel that she got her money's worth, and (I can't deny it), I want to be sure that she leaves the office happy enough with me to want to come back again the next time she needs medical care. My first introduction to most of my patients has been because of the ubiquitous cold. If they like my style, perhaps they will return when they have an illness of more importance to both of us.

I now have enough information to move toward a tentative diagnosis. I have not yet used my examining equipment, but the equipment of observation and analysis has carried us well along the way to our goal. My framework of analysis is useful to the extent that it allows me to organize centuries' worth of accumulated information, to assist the patient in organizing the frightening and mysterious messages being received from within, and to complete the desired tasks in a reasonable time span. But just like any other tool useful for whittling reality down to size, the analytic framework may blind me to what is really important--the patient's needs. While making use of the many presumptions that allow the intelligent manipulation of the patient's physical condition, I carefully shape my approach so as not to exclude the essential goal of a satisfied patient. Rather than objectifying the patient in the nineteenth-century model of the laboratory scientist, I must realize that the observer, the observation, and the observed form a temporary union. This requires serious compromise of the traditional positivist approach to knowledge via investigation and analysis. Instead of the biomedical model, I may call upon models more familiar to the priest, the advice columnist, or the used car salesman.

With uncertainty all around me, I sometimes long for the security that science appears to offer. Unfortunately, science can no longer offer the comfort that I need. Positivism has long since given way to probability. Modern science has discarded traditional notions of certainty, but the applied sciences have failed to fully absorb the message. An ordered, determinate universe of accurate diagnosis and definitive treatment will always be just beyond my grasp. My patients' fears fall through the cracks of the probabilistic certainty that remains.

As knowledge is created, I'll gently guide (or, to be blunt, manipulate) the patient toward a concordant view of reality as I interpret it. The creation of therapeutic knowledge depends upon a partnership between patient and physician; temporarily, the authority still rests with the physician. I imagine that even the most radical advocate of patient autonomy would quickly begin to feel ill at ease in an office visit that was totally undirected. To the extent that I abuse that authority by ignoring the patient's goals, the clinical encounter will be a failure, whatever the results of the treatment.

Is it possible to be manipulative while at the same time being solicitous of the patient's needs? Is it ethical? I would answer yes to both questions. While I have discussed my encounter with my patient and her cold from my point of view, the actual process of the creation of therapeutic knowledge must be a joint responsibility. My patient and I will try out different compromises until we find one that is satisfactory for both of us. But it is my professional responsibility to ground our choices as close to rationality as I can. This requires certain limits on my flexibility, and thus certain exclusions of possible actions requested by the patient. As will be seen, I sometimes have my doubts about the existence of ultimate truths, but that doesn't stop me from refusing to provide penicillin injections for viral illnesses. If I must stand my scientific ground with every patient, I have to find effective non-confrontational methods to allow me to make it through the day emotionally intact. Poker players, negotiators, and physicians are under no moral obligation to reveal all of their cards too early.

Historians and Literary Critics

Contrary to what I was taught as a medical student, the evaluative process so far described is highly directed, and excludes far more than it includes. Since only ten minutes is allotted per patient, I long ago learned the value of efficient historical research. While I take care to ensure that the patient receives the cathartic benefit of narrating her story, I am compelled to set definite limits. The patient is trapped in a morass of undifferentiated feelings; I will insist on organizing the feelings into symptoms, fearlessly ignoring those symptoms that don't appear to contribute to the diagnosis. I note the connections the patient makes, even while discounting them. Ultimately, I use the same approach and tools as the historian. First, we filter the witnesses' reports in search of an interpretable pattern. We then apply a critical method of analysis to determine the reliability and validity of the information. I know from my unwary past that the patient will ignore the significant, exaggerate the trivial, and sometimes falsify the critical. I absorb everything the patient offers, transforming it from the idiosyncratic into knowledge with clinical meaning. The construction of therapeutic knowledge has begun.

A favorite pejorative in the medical record is "poor historian." This is used to refer to the patient who is unable to supply an easily assimilable narrative. One suspects that the poor historian was actually the other half of the dyad: it was simply too much work for the physician to establish a dialogue. Actually, even dialogue isn't always enough for me. A telephone conversation about a patient's symptoms will often mislead me. I need nonverbal clues to truly get the message.

The dialogue works both ways. The patient will understand far more about his symptoms after having once told his story. Every medical student has been embarrassed by a patient's revisions of the history when the patient is re-questioned by the professor who has just had the case presented to him by the student. The same process often takes place when I send a patient to a major medical center. The act of triage has cast light for both patient and consultant on the critical components of the illness. The "local medical doctor" always takes the rap for being so slow to see the obvious.

More like the literary critic than the historian, I have little inhibition about inserting my own being into the interpretation of meaning. I will note my emotional reaction to the patient and the narrative and make use of it for diagnostic purposes. If, during the visit, I start to feel anxious or blue, I may be expressing the emotions that the patient is unable to bring to the surface. (There is a necessary assumption here that the psychopathology isn't arising from within myself.) The subjective data turns out to be just as subjective for me as for the patient. I recognize that there are infinite interpretations of the patient's feelings; I choose one of them and feel free to announce it as correct. And why not? If truth is contextual, every patient and physician will create his own.

Interesting parallels may be drawn between the postmodern movement of literary criticism known as post-structuralism or deconstructionism, and the principles of medical diagnosis. The deconstructionist explicitly moves beyond structuralism, a dominant explanatory framework in the twentieth century for linguistics, anthropology, and criticism. Structuralism was based on semiotics, the science of signs, and its analysis searched for underlying structural phenomena to explain the existence of various human institutions, behaviors, and beliefs. These phenomena were reducible to the signifier and signified, the components of every sign. While the relationship of every signifier and signified was initially arbitrary (the word H-O-R-S-E and the idea of a horse), once they became linked they always bore a predictable relationship to each other, and were transformable by describable operations to other sets of signifiers and signifieds. In the spirit of scientific positivism, semiotic meaning was inherent and identically available to every observer.

The deconstructive enterprise is based on the rupture of the linkage between signifier and signified. The signifier has become "floating": its meaning is only discoverable by its contextual relationships, not by its inherent characteristics. It is necessary to examine not only the superficial semiotic message of the text, but also the unstated assumptions of the author as perceived by the reader. The vocabulary, the orthography, and even the margins contain the real message. Since each reader provides his own interpretive context, meaning is no longer fixed. Reliable transmission of information from the author to the reader is revealed to be a mirage. The philosophical end-result is often a free-for-all of competing interpretations: the very idea of a single "correct" interpretation has been discarded. The author's intention becomes unknowable, even to the author. The only escape from this relativistic anarchy is a careful dissection of contextual clues, using the techniques of historical and semantic analysis. Even then, the best that a reader can ever claim is: "This interpretation is true for me at this moment."

Physicians may disapprove of these ideas when it comes to literature, but they seem to practice medicine as if they invented deconstruction. Pathognomic signs are rare curiosities; all other symptoms and signs float well out of the control of doctor and patient. The narrative history of my patient's cold possesses very different meanings for her family, for her boss, and for her physician. "Vital" signs, the cloudiest of windows into the body, have been transformed into serious objects of worry for my patients, while they contain no definite meaning for me. Each rise of one degree of temperature signifies worsening disease to my patient; fever only signifies altered homeostasis to me. The public education campaign of the American Heart Association has been so successful that patients commonly think heart disease every time they have a neck, jaw, shoulder, arm or hand pain, whether or not there is associated chest pain. The aching muscles of the common cold are transformed into serious portents. Daily, I discuss with patients the looseness of the semiotic connection between symptom and dread disease. Contrary to the American Cancer Society, the "Seven Warning Signs of Cancer" might better be classified as the "Seven Signs That Could Possibly Mean Cancer but Probably Only Mean That You Will Be Unnecessarily Frightened and You Will Undergo Several Unpleasant Tests Before You Are Given Back the Peace of Mind That You Lost When You Took the Seven Warning Signs Too Seriously." My patients routinely terrify themselves by browsing through home medical encyclopedias until they find a diagnosis with a single match of symptoms. But until a symptom or sign is placed into the context of a patient's life, and the other symptoms or signs that the patient has or does not have, it is devoid of meaning.

The deconstructionist similarity extends well beyond the meaninglessness of the individual sign. Patients may cringe at the thought, but the advice they receive may sometimes depend as much on the doctor they choose as on the illness they have. Insurance companies that introduce presurgical second opinion programs soon discover that doctors commonly disagree on the appropriate approach, even to seemingly simple problems. In fact, studies of decisionmaking have found that when a hypothetical case is presented unchanged to the same doctor after a delay, a different recommendation often results. [1] If this is true when the choice of decisions is limited to "cut!" or "don't cut!" then what is to be expected from the evaluation of the melange of physical and emotional symptoms the patient presents during the office visit? When I fail to convince a patient of a particular approach to a problem, and if I don't feel that I can compromise, it is time for a consultation with a specialist. Over the years I've identified consultants who share my attitudes toward important issues in their field. This is not conspiracy, but merely common sense. Even so, I am often chagrined at the discrepancies between each physician's reasoned advice. We looked at exactly the same signs, but when the context changed, so did the meaning.

These post-structuralist musings may call forth a reasonable criticism from a less literary-minded colleague: "The written text may have lost its anchor and have floated free, but the patient-text is connected to terra firma by underlying organic dysfunction. I may not be clever enough to discover the patient's problem, but someday the pathologist will get some portion of the patient to study, and then a definite answer will be found. Our real problem is not the inadequacy of modern science, but rather the inadequacy of current technology. One day scientific progress will fix this problem and that will put an end to your sophistry."

Unfortunately, the pathologist faces the same issue that I do, and that the advanced technologist of the future will face: the scientific study of human beings is constrained by the very humanity of the scientist and the subject. We cannot think about the world without symbolizing it, but a symbol is set free of its origins as soon as it is created. Our language frees us from ignorance, but at the same time frees itself from our aspirations of control, while imprisoning us within the limits of our symbols. My favorite pathologist has informed me that he possesses a Muse for use when technology fails him. (He clearly is ready to do family practice.) Still, I do not expect an inspired reshuffling of his preconceptions to create a new nosology the next time he performs an autopsy and finds himself unable to find anything seriously wrong with his patient other than apparently being dead. Our ideas of disease limit our perceptions; new ideas in the future can do no more than provide us with a new set of constraints.

I do not necessarily wish to celebrate the deconstruction of the patient. The elusiveness of meaning is merely one more interpretive obstacle to be overcome on the path to therapeutic knowledge. If I actually read my patient like a book, I would risk falling into the same objectification and dehumanization of the suffering person in front of me that the physician who has absorbed without question the ideology of science must risk. Books may be put down only partially read, intentionally misread, or even destroyed out of pique. There is nothing objectionable about failing to take a book seriously; the same cannot be said for a patient. My best defense against forgetting the actual human purpose of my office and my profession is to keep my analytical equipment clearly labeled as useful tools, and not to mistake the diagnosis for the person.

If the creation of therapeutic knowledge is non-reproducible, a serious challenge is raised for those who yearn for the standardization of medical care. The current rage among economists is the creation of consistent medical practice patterns to assure cost-effective, quality care. It is apparent that those who would fit physicians and patients into a rational system possess a different view of medicine than I do. I see these efforts as procrustean dreams, bound to create pain for everyone concerned. One such economic fantasy is the application of industrial engineering techniques to medical quality assurance. [2] But no widget factory exists in which every machine, every process, and every product is continually redesigning itself. Talk of automated, computer-managed medical care does not make me fear for my job security: there will always be a place for impressionistic meaning created by nonartificial intelligence.

The modern refusal of scientifically minded physicians to accept that medicine is inherently relativistic must contribute to the conflict between the medical and legal professions. Fear of malpractice suits is never far from the physician's mind. The worst fear is not financial, but rather to be caught in the middle of the Alice in Wonderland of a trial. The ideology of science cuts both ways: while the physician complains of the lack of scientific method in the courtroom, the attorney holds the physician to an unattainable scientific standard. Even though contextual notions are the essence of the legal system, they are often ridiculed in the courtroom. Ambivalent though the attorney may be about the relationship of Truth and Justice, he will demand the physician defend the ideals of accuracy and certainty. Physicians might desire a public examination of context, but must recognize that they are held to a standard of diagnosis and treatment that has no place for literary notions. The truth, the whole truth, and nothing but the truth--I don't expect to find it soon, either in my office or on the witness stand.

Therapeutic Knowledge

As the office visit for my patient's cold proceeds, the gathering of apparently objective data allows me to revert more comfortably to the role of the natural scientist. The physical examination and laboratory tests have a welcome "hardness" about them that ought to be a relief from the relativity of the history. However, the late-twentieth-century scientist has long ago discarded the stereotypical scientific method. Choices are made and options discarded on the basis of an antecedent, partially formed, tentative hypothesis-diagnosis. I choose which portion of the physical examination is warranted, and which laboratory tests will aid in the acceptance or rejection of the diagnosis. These carefully chosen mini-experiments rarely provide any true surprises, but an unexpected finding occurs just often enough to keep me from adopting a purely intuitive diagnostic mode.

Just like the critic, I must pay attention to the unstated messages of the body-text. Instead of margins or spelling, I concentrate on hidden cavities and subtle changes in facial expression or muscle tension. My patient may turn out to have a red throat, or an unanticipated wheeze. I am always hopeful that I will find a reddened eardrum: this allows me to prescribe an antibiotic without hesitation, thus avoiding the usual conflict between the desires of my patient and the precepts of my teachers. For some reason, red ear equals guilt-free excuse for an antibiotic prescription for even the strictest of physicians, even though red ears may often be viral in origin.

Even after the examination is performed, the interpretation of the results once again blurs the distinction between objective and subjective: striking inter-observer variability exists. Every physician makes his own decisions about the value and meaning of a particular finding: abnormality is in the eye of the beholder. The wished-for red ear is notorious for vanishing in between examinations. Once again, the deconstructive position is revealed to be at the core of the medical diagnosis.

The knowledge obtained from the history, physical, and laboratory findings is now entered into the final stage of the continuous array of self-correcting hypotheses and deductions that have been created throughout the office visit. This ever-evolving array constitutes the true scientific method. The actual final pathway to Truth cannot be described with logical terms: as with all hypotheses, a nonverbal creative event lies at the heart of every diagnosis. When it comes to colds, repetition has long since dulled the magic of creation. Even so, my patient is understandably quite interested in the outcome, and this serves to maintain my enthusiasm.

A point finally arrives when I believe that the correct diagnosis has been reached. A degree of uncertainty will always remain. I'm comfortable with this; I can only hope my patient will be too. Throughout the office visit, we have been dealing with far more than just her cold. We have been conducting an unconscious process of introduction, negotiation, and personal expression--in other words an average human interaction. As she has revealed herself to me through narrative and examination, I have revealed myself to her through personality and method. Together, we now know each other well enough to join forces against her discomforts. The basis of therapeutic knowledge finally exists, and only now can therapy be chosen.

I may decide to offer an antibiotic, or recommend symptomatic treatment, observation, and close follow-up. I have the many successes of the biomedical model to aid me: there are numerous available medications, and endless information is available on their proper, scientific usage. The standard of care is clear enough, at least to those whose livelihood does not depend on catering to the whims of their patients. Unfortunately, my advice may be affected by factors that were never contemplated by my teachers. These include the patient's preconceived notions of appropriate treatment, my tolerance for long discussions on the scientific indications for a particular medication, or the suspicion that if I write one more prescription for penicillin that day I will surely go mad. An everpresent conflict exists between the patient's demand for a quick fix antibiotic prescription and the biomedical model's proscription against inappropriate antibiotic usage. I am caught between id and superego, with predictable results. Therapeutic neurosis and therapeutic knowledge are found to be unavoidably linked.

In the choice of treatment, the scientific method can only take me and my patient so far. For the rest of our worries, I must rely on personal experience, whim, placebo, and finesse. Ideally, this empiric approach would be self-correcting over my career, ultimately converging upon reality. In actuality, erroneous practices remain rampant, due to reinforcement by my coincidental successes and by my ad hoc reinterpretation of failure.

If I am willing both to educate the patient about the inherent uncertainties of medical practice, and to guide the clinical encounter to the successful creation of therapeutic knowledge, the ultimate success of the chosen therapy becomes of less immediate importance to the patient. You may be sure that I will hear about it if things do not go as planned; but if I have done my job properly there will be a minimum of anxiety and a striking absence of anger. The creation of therapeutic knowledge has already initiated the cure of the sufferer's disease.

I do not call for the abandonment of the scientific method, but only acceptance of its limitations. The complexities of human life cannot be comfortably reduced to logical formulas. Knowledge may be useless without a rational connection; it is surely absurd without a human core. As the twentieth century comes to a close, Science and Art continue to bicker over who is to blame for the state of the world, and who will have what it takes to fix it. It is my belief that in medicine, as in the rest of life, the quarrel is not between opposites, but only between mirror images. It would seem to me past time to take Tweedledum's advice to Tweedledee to heart: "Let's fight till six, and then have dinner."

Relativity, context, uncertainty--these notions are no longer new; many might even consider them banal. Why, then, do they appear so radical when applied to a visit to the doctor for a cold? Perhaps it's the novelty of applying academic theory to everyday life. More likely, it is because when our bodies are involved, we are not eager to trust our futures to philosophers. I may sometimes suspect that ideas are interchangeable; I am sure that my body is unique and irreplaceable. The remarkable successes of modern science hold out the hope that technology will repair the ills of the body; the spirit is left to its own devices. But every patient eventually learns the same lesson: medicine does not renew, but only temporarily relieves. And true relief lies not within the body but within the soul. As a physician, I can be certain of no more.


[1] David M. Eddy, "The Challenge," Journal of the American Medical Association 263:2 (1990), 287-90.

[2] Glenn Laffel and David Blumenthal, "The Case for Using Industrial Quality Management Science in Health Care Organizations," Journal of the American Medical Association 262:20 (1989), 2869-73.

Charles Radey, a physician in Gaylord, Michigan, recently completed a fellowship in bioethics at the Cleveland Clinic Foundation.
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Author:Goldstein, Jared
Publication:The Hastings Center Report
Date:Nov 1, 1990
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