Saturday, 2 June 2012

Medical Travels around the Möbius Strip

Jeffrey Levett, Professor, Management of Public Health [Greece]

Medicine is a timeless art, as contemporary as human genome research and older than the Pyramids and the Acropolis. In the earliest of times, medicine was an art, which took its place at the side of poetry and painting; today it is a science placed on a par with mathematics, astronomy, and physics. According to Thomas Sydenham [1624-89] the origin of medicine was then as mysterious as the source of the Nile. Medical practice is based on trust and faith between patient and doctor and is summed up in the well known Hippocratic tradition: life is short, art long, opportunity fleeting, experiment treacherous, judgment difficult as well as in four principles: telling the truth, not doing harm, not taking advantage and keeping secrets.

The ancient Greeks recognized and understood the importance of reason and considered medicine to be the mother of science. Alcmaeon of Croton, a student of Pythagoras applied a theory of opposites to questions on health and disease. Clearly, medicine in the ancient world was a mixture of the Aeolian Arts and Ionian Science. Opposites, comparisons, dualities and dichotomies were all part of the ancient Greek world.

A doctor’s work is arduous and complex. It requires the highest faculties of mind and a constant appeal to the finer feelings of humanity. William Osler said that the physician needs a clear head and a kind heart. He emphasized the importance of what he called the education of the heart and the moral side of man, which must keep pace with the education of the head.

Permit me first though to make some brief comments on present day Greece, a small country with a large history, and now in the clutches of the Trojan horse of the troika and an economic crisis with an unfolding creeping disaster for health. Social, economic and health damage is evident. In protest to the austerity measures of the Greek Memoranda, unfortunately, one in five Greeks voted for ugly and fanatical nationalism with anti-immigrant rhetoric, in the recent elections. As Bertrand Russell (1872-1970), English logician and philosopher said: “Neither a man nor a crowd nor a nation can be trusted to act humanely or to think sanely under the influence of a great fear.”

Of note: as population vulnerability increases, Greece once suicide-free has to deal with a rapidly emerging epidemic, the erosion of excellent health indicators and a rising growth of poverty. The worst threat to public health has come from politics and paradoxical political behaviours. Indeed politics has pursued actions leading to the dysfunction and demise of institutions harmful to successful development.

In the face of considerable politically sponsored hardships of the people the best efforts of medicine and public health will be needed to help pull Greece through the coming social turmoil. Once a symbol ‘of escape from the prison house of [the Ottoman] empire’, in [best] or out [worst] of Europe Greece is in a no-win situation for health damage will accumulate. Keeping the Greek cradle of civilization rocking in Europe requires your help and your goodwill.

An American tourist from Dakota was pleased to learn that Greeks are great fans of NASA’s space projects, for wherever he went he ran into the name Apollo. It was Apollo who wrought destruction and pestilence on the Greeks outside the walls of Troy to give us the first ever recorded epidemic in history. What followed was Greeks bearing gifts with the Trojan horse. It was Apollo who recognised that the slain Hector was a better man than Hercules. Homer’s text records all of these epic events.

Additional English words derived from Greek include austerity, panacea, agape, comedian, gnomon, crisis, chronicle, stentorian, echo and phrases such as KNOW THYSELF, HEALTHY IN BODY-HEALTHY IN MIND, ALL THINGS IN MODERATION, ONCE Said, DOG AS MAN’S BEST FRIEND and THE FACE THAT LAUNCHED A THOUSAND SHIPS or anyone causing disaster.

The most famous text in Western medicine, the Hippocratic Oath also begins with Apollo: I swear by Apollo and Asclepius my witnesses, that I will fulfil according to my ability and judgment this covenant. I will remember that there is art to medicine as well as science. When the art of medicine is loved, then humanity is also loved. Hippocrates provided us with a dichotomy when he delineated between two things, science which leads to knowledge, opinion which denotes ignorance. This holds great significance for contemporary Greece.

Hippocratic medicine emerged on the Island of Cos, and still represents the ethical gold standard or an ideal for the compassionate, discreet and selfless doctor. the virtues of Hippocrates are illustrated by three legends; eradication of the Athenian plague demonstrated his brilliance as a doctor; his refusal to work for Artaxerxes, King of the Persians demonstrated his patriotism as a Greek; while his cure of love-sickness of King Perdiccas revealed his artistic skills. However, when Daniel Sokol a medical ethicist asked medical students to name famous doctors in the history of medicine, their first answer was Harold Shipman, the GP who murdered hundreds of patients, second House, the fictional TV doctor. SOKOL breathed a sigh of relief with their third answer, Hippocrates.

We have much to be thankful for with the mortal Asclepius and his offspring: Iasso, Panacea, and Hygiene, goddess of public health, with Peitho, goddess of persuasion, philosophy and ethics. When Asclepius was elevated to divine status, Temples were built throughout the Mediterranean.

Just as a reminder the Möbius strip or band is a surface with only one side and only one boundary. It was discovered independently by German mathematicians August Ferdinand Möbius and Johann Benedict Listing. I suggest that the Möbius strip is a different and better model to conceptualize the dichotomy or duality of the art and science of medicine, better than a two sided coin, a pendulum or a fixed or variable sum model. Medical history seems to be a spiral path, oscillating between art and science as it ascends, and sometimes descends with current reality adding its own titbits and deviations. With respect to the concept of a fixed or variable sum of art and science in different proportions, the resulting mixture depends on the historical moment and the makeup of the practitioner. The mixture undergoes change with the swing of times pendulum. Unlike the two sides of a coin which contains an element of “either/or”, art and science remain inseparable in the unity of medical practice.

Leading up to and throughout the Industrial Revolution a downward trend was noted in medicine. Physicians were more concerned with isolation of patients than with environmental sanitation and medicine offered little to the poor. At the bottom of the social ladder the bulk of the population suffered severe reductions in their already low living standards. Chronic hunger and malnutrition were the norm for the majority of the population and life expectancy was about 35 years mainly due to malnutrition. It was a period of medical nihilism since the old medical system was discredited through the use of clinical statistics. Not until the development of bacteriology and pharmacology in the latter part of the 19th century did medicine revive and direct medical care was provided for the poor.

But before the world, went global confusion reigned and the Greeks called it chaos [the initial system of complexity]. The cosmogeny [creation myth] of the Ionian world produced Gaea, plants and animal life, fully sustained by life-giving rains with environmental balance, sustainable development, oxygen food and water. At the end of long healthy life, men fell into a deep sleep and returned to the earth. The first golden age achieved the squaring of the mortality curve: no childhood diseases, no chronic disease, no accidents and no disasters. There was no need of doctors, health services, vaccinations, imaging technology, spinal cord units, or evidence based medicine. Health management, economics and policy as well as ethics were all unnecessary. Perfect public health was the status of the world. But it could not last. Along came disaster.

Forewarned, by the early warning system of Prometheus, Deucalion built an ark to survive the catastrophic flood. Survival reflected proactive management, use of preventive measures smart tactics and a responsive strategy. By following the command of Zeus, the supreme strategist, the land was repopulated. Stones thrown over Deucalion’s shoulder became men; stones thrown by his wife Pyrrha became women. Prometheus understood well the misery of a cold hearth in winter and gave fire to mortals to relieve their suffering, becoming the embodiment of social medicine. Today the WHO coordinates a global warning system for health threats.

Development in biomedical and information technology the faith in Medicine is very strong. The recent incursion of 'evidence-based medicine’ into medical practice seems to clinch the argument; medicine is a science! However, clinical guidelines are frequently modified or changed and half of what is said to be true today will be proven incorrect in the next five years. We don't know which half it will be. Will it be the half of medicine considered art or will it be the half thought to be science? Mahajan (2006) cautions the physician not to allow scientific medicine to blunt his humanity, to ignore ethics and the need for empathy. Hegde (1999) is of the view that doctors in all cultures from quacks to witchdoctors have succeeded in practice mainly because they show concern for their patients.

Farokh E Udwadia says that modern medicine has been robbed of humanism and that sympathetic communication and empathy with the patient is failing. As a result of mechanization, over specialization and commercialization of medicine, values have been lost and doctors are forgetful of the art of medicine. He goes on to define the art of medicine as the artful application of science to the holistic care of the patient.

When the Senior Contributing Editor of JAMA Dr. Therese Southgate was asked what has medicine to do with art? She answered: Everything! Medicine is considered both a social calling and an art of doing. At its best, it employs the finest tools of medical knowledge and the best skills of the physician. Benchmarking has recently entered the medical arena, permitting process and quality to be improved.

At the very beginning of my medical travels along the Möbius Strip I was reading The Mind’s Eye by the ophthalmologist Oliver Sacks a great story teller who has taken the most basic tool of medicine, the patient history and turned it into an art. Like Hippocrates he listens to the patient and responds to his concerns and preferences. In calling up philosophy, he introduces communication as a dichotomy of “saying and showing” as in the child’s activity of show and tell and leads us to the belief that man’s ability to perceive, is a fixed sum: loss of sensory perception in one organ triggers gains in others. William Osler taught the art of medicine utilizing the stethoscope, physical exam, and patient history. The patient was a text to be read. He articulated that “clinical medicine will always blend the art of uncertainty with the science of probability.”

In Captain Corelli’s Mandolin set on the Island of Cephalonia we meet up with the local doctor, practicing his arts. Under his arm, he has something for the cooking pot. By irrigating the ear of an elderly man he flushed out a petrified pea, lodged there for years to restore his hearing. In the eyes of the astounded wife, a miracle had been performed. Tucked in the doctor’s pocket was a prostitute’s promissory note to be redeemed at some future date for past services rendered. The note brings to mind an outstanding debt of Socrates. As the philosopher contemplated hemlock, a cock was sent to Asclepius making sure that after death there would be no unpaid debt.

Henle, of the proximal and distal convoluted tubules refers to the artistic side of medicine, while Virchow the Prince of Art and Science distinguishes between the artistic from the scientific while and teaching us that medicine cannot be removed from the social context.

Hippocratic medicine reflected the emergent scientific philosophy that things and events in the world result from natural causes. It began with the Ionian philosopher, Thales of Miletus (c. 625-546). His speculations about the natural world are regarded as an important turning point in Western scientific thought. Before Thales became a philosopher he made a lot of money as an entrepreneur. Armed with knowledge of astronomy and weather, he predicted a bumper olive harvest. In the darkness of winter he set about hiring all of the olive presses in the region. When the olive crop arrived he rented out the presses at a high price. It was the first killing in the oil market. After that, citizens of Miletus kept their distance from the wily Thales and he philosophized in peace for the rest of his life.

Aristotle pointed out that one size does not fit all, and considered Hippocrates an excellent geometer but a complete fool in everyday affairs. Because of his stutter Aristotle would have benefited from modern therapy. Democritus who gave us the atomic theory was considered crazy by most because he laughed at everything but Hippocrates said that his problem was just a happy disposition.

The Greeks clearly recognized that "when health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied." [Herophilus]. This wisdom is reflected in statements of Disraeli during the Industrial Revolution and Roosevelt [1932] in the Great Depression: “the health of the people is the foundation upon which all their happiness and all their powers depend.” and that “nothing can be more important to the State than its public health; the state’s paramount concern should be the health of its people”. Buddhism says: without health life is not life; it is just a state of languor and suffering and an image of death. Inscribed on the parchment of the first Greek diploma in public health, eighty years ago are the words of Eleftherios Venizelos “Χωρίς Υγείας Άβιος Βίος” (Without Health, Lifeless Life). The symbolism and significance of the phrase for public health are obvious. Without a healthy population, community life can be unbearable.

History teaches us that medicine as a product of the marriage between science and art when applied to the care of the individual and public heath with its Harem of interdisciplinary sciences when applied to population groups [community, elderly, mothers and children, handicapped] make even the worst situation endurable. With the use of appropriate public health control programmes and optimal medical care the burden of disease can be reduced in any society. Health is of the greatest importance to society and at times may determine its very existence. Social solidarity emerged not out of the golden age but out of the squalid conditions of the industrial revolution at a time of great political and social change. It leads the state to take responsibility for its people, through measures for sanitation and environmental quality, which is the criterion of any civilized society and which no industrial society can escape today.

In the sixteenth and seventeenth centuries, Turkish scholars differentiated between medicine as a science whose objective is the study of disease and the restoration of health, and the craft of medicine that requires a manual skill such as surgery, which they considered more of an art than a science.

Every day the art and science of medicine is practiced and as a result, countless decisions are made about when to stop or start medical treatment. Each decision contains an analysis of benefits versus risks, of doing something or not. No medical treatment is perfect or suitable for everyone and no doctor is infallible. Large sums of money are invested to protect the public from disease and healthcare is big business in a market place where science meets big money but not all research evidence makes it into the public domain. Medical history is replete with examples of the benefits of a treatment being oversold and potentially serious side-effects being buried. This wastes public money and can cost lives. Less than 15 percent of medical decisions are based on "appropriate evidence." Medicalization of birth and death, has rendered many people lifelong patients which Ivan Illich, 1975 based upon “the shocking extent of post-operative side-effects and drug-induced illness in advanced industrial society” and coined the term iatrogenesis.

Practitioners of human factors engineering believe that there is much that medicine can gain by using concepts from aviation safety, where it is recognized that it is dangerous to place too much responsibility on one "superhuman" individual and expect him or her not to make errors. Disparities in quality of care are often cited as a cause of controversy. As a result of complaints and medical errors, reporting systems and checking mechanisms are becoming more common to identify sources of error and to improve practice.

Atul Gawande developed the WHO’s “surgical safety checklist” to improve the outcome of surgical interventions by reducing morbidity and mortality on a global level. Out of the 230 million operations performed worldwide in 2008, “three percent resulted in major disability or death, while at least half of the time, adverse events are preventable. However, if medical errors were eliminated and all mysteries solved, ‘medicine’s ground state would still be uncertainty’. Medical experts’ estimate that half of all surgical operations and other medical procedures remain without strict scientific evidence of their efficacy and safety are questionable. Wisdom for both patient and doctor is to find how to cope with this uncertainty.

Doctors are healers, wise in art and science, experienced in fighting disease through prevention, cure, and rehabilitation. You are at the forefront in caring for patients to bring back wholeness, within their social environments. Your art of medicine is the human touch, going the extra mile to serve the patient as well as the literal art of medicine or fine arts applied to medical themes and to therapy as your scientific program demonstrates. The link between doctor and artist is the relationship between health and disease, sickness and suffering and the roles of fate and chance. Consequently, the fine arts of the artist can inform the doctor on the human response to disease. "Art" is indicative of the doctor’s attitude toward nature and patient, which is quite similar to that of an artist toward nature and his creation, while "science" connotes a judgment by measuring. By calling on both, the patient can be viewed from two different angles. Just as medicine achieves balance between art and science, all arts, paintings or sculptures are balanced in some way, symmetrically or asymmetrically but both reveal an underlying unity.

Carol Aschenbrener [AAMC] says physicians need a strong foundation on which to base the art to communicate and the heart to care.

Many think that a separation occurs today between the sciences and the humanities because of the ascendancy of science. Particle-wave duality: a dichotomy between symmetry and asymmetry and space age biomedical technologies. However, warmth, sympathy, and understanding can still outweigh the surgeon's knife or the chemist's drug and the art of medicine can still be refined and the science of medicine can still be improved. Along the Möbius strip there are no traffic lights and no limits.

1 Except for the trip on the Möbius Strip, I have not added to what others have said and written on the art and science of medicine. It is still a great wonder as to how it was possible that just a small number of people set the stage for western civilization?


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