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Doctoring: From art to engineering
SUSPENDED JUDGMENT Doctoring: From Art to Engineering William A. Silverman, MD Greenbrae, California
"We cannot s e e m to live without high-technology medicine; we cannot seem to
live amicably with it" [1]. The studied outward behavior of doctors when ministering to their patients has long been recognized and admired as an important "art form" in medicine. The performance is meant to reduce a patient's anxiety by demonstrating as much subjective concern for the person as objective interest in the presenting medical problem. And the doctor's convincing priestlike air of certainty in speech and in action is meant to persuade the patient to suspend all disbelief. Early in their schooling, medical students pick up on the importance of appearances, and imitate (often unconsciously) an admired friendly, but authoritative, "bedside manner." Budding doctors try to reproduce the facial expressions, poses, and tone of voice used by their most convincing role models. Unschooled (but not necessarily uncaring) frauds posing as doctors have performed successfully in medical settings, convincing patients and medical personnel completely and for surprisingly long periods of time, before they are unmasked. The image of the doctor as an authority but, above all, a dedicated friend was romanticized over 100 years ago by Sir Luke Fildes in his painting "The Doctor" [2]. It depicts a very distinguished-looking practitioner who has made a call at the cottage of what seems to be a poor family. He is shown sitting at the side of a deathly ill child lying on a makeshift bed set out on two chairs in a very dark, sparsely furnished room; the mother is standing, reverently, in the background. The doctor is leaning forward, chin cupped in hand; there is a kindly, puzzled expression on his face; it is easy to believe he is keeping a night-long vigil at the side of his dying patient. In the quiet scene, the medical profession is shown in its most endearing role, as the epitome of dedication and compassionate concern. When the painting was first shown in London, the artist's wife could not get near it because of huge crowds who came day after day to see the new piece in the art gallery. A photogravure copy of the painting became the most popular print ever issued by Agnew's,
Received May 20, 1991; revised July 22, 1991. Address reprint requests to: William A. Silverman, MD, 90 La Cuesta Drive, Greenbrae, CA 94804.
ControlledClinicalTrials13:97-99(1992) © ElsevierSciencePublishingCo., Inc. 1992 655 Avenueof the Americas,New York,New York10010
97
0197-2456/92/$5.00
98
W.A. Silverman a London printing firm. For many years, prints of the painting were seen hanging on walls in doctors' offices, in hospitals, in pharmacies, and in private homes all over the world. "The Doctor" was eventually reproduced on two postage stamps, and the image became familiar to millions of people as a symbol of the compassionate "art" of doctoring. John C. Burnham, a historian, has found that prior to the turn of this century, physicians in the United States were not always highly esteemed; they were often criticized for their pretensions and their greed [3]. However, the tide of public opinion shifted after medical, and particularly surgical, successes. The admirable image of the doctor was very much in evidence in the United States during the first half of the present century. Burnham has labeled this period "American medicine's golden age." Publicity about the profession became increasingly favorable. Burnham found that by the 1930s American doctors enjoyed considerable social prestige and were much admired for their work. Medicine came to be regarded as a model profession, he found that opinion polls from the 1930s to the 1950s consistently ranked doctors among the most highly admired persons, equal to or higher than supreme court justices. In 1952, an elderly doctor remembered that when he was young, the townspeople of Worcester, Massachusetts customarily tipped their hats to the physician as he passed by [4]. Although medicine was becoming increasingly effective in the first half of this century, Burnham notes that public attention was focused not so much on the profession's technical accomplishments, but on the individual doctor's "priestly" role. During the "golden age" there was preoccupation with a Fildes-like image of the doctor as a wise and trusted advisor. Though the "old-fashioned family doctor" was passing quickly from the scene, people seemed nonetheless to yearn for a warm personal relationship furnished by the idealized country practitioner. When criticisms about doctors began to mount in the 1950s, they reflected a continuing demand for personal attention rather than technical competence. The complaints about the indifference of doctors have become more frequent and have grown louder with the growth of specialization and the increasing complexity of treatments administered by groups of doctors practicing in hospital settings. The change in the form of doctoring since the turn of the century is, of course, striking: from the passive priestly model (a solo practitioner making a house call, sitting quietly at the bedside of a dying child) to the current hyperactive "engineering" model (a highly efficient team of medical experts in an intensive care unit working frantically to keep a deathly ill child alive with the full panoply of modern medical hardware). Doctors find it hard to understand the paradox: revered when they were relatively ineffectual, they now find themselves increasingly rebuked when they are able, for the first time ever, to change the expected course of so many disabling and fatal disorders. The burgeoning increase in medical knowledge holds the promise of ever more dramatic control of disease, yet the future is clouded if the beneficiaries continue to resist expansion of the limits of professional autonomy. It is of some interest to recall that during the early years of American medicine's golden age scientists' dreams about controlling biological processes were just beginning to grow. For example, at the end of the 19th century,
Doctoring: From Art to Engineering
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Jacques Loeb was successful in achieving artificial parthenogenesis in sea urchin eggs, and he became convinced about the transformative potential of science [5]. During the years 1890-1915, Loeb was making strong claims about the power to control life. Biology in the 20th century should be organized around engineering aims, he proclaimed; the "engineer in biology" would no longer be satisfied with a quest for mere understanding, but was to be a man of action who used scientific insights to rule over nature. Echoes of the point of view that conflates medical science and technology can be detected in the ongoing struggle about the limits of doctors' actions. The disagreements reflect the failure to make a clear distinction between the store of scientific knowledge available at any given time, and the circumstances and conditions in which this knowledge is applied. Quite apart from what is purely technical and instrumental about medical practice, Freidson argues [6], there is embodied in it an inescapable moral element. The autonomy ceded to physicians to determine the content of medical work may be appropriate, he concludes, but a grant of the sole right to determine the practical modes of applying that knowledge cannot be justified. Is modern medicine responding to human need, critics want to know, or is it creating needs to which it responds?
REFERENCES 1. Rosenberg C. The Care of Strangers. New York, Basic Books, 1987 2. Trueherz J (Ed): Hard Times: Social Realism in Victorian Art. London; Lund Humphries, 1987 3. Burnham JC: American medicine's golden age: What happened to it? Science 215:14741479, 1982 4. Lundy JA: Arrow wounds. N Engl J Med 246:~! 446, 1952 5. Pauly PJ: Controlling Life. Jacques Loeb and the Engineering Ideal in Biology. Oxford, Oxford University Press, 1984 6. Freidson E: Profession of Medicine. New York, Dodd Mead, 1972
"We cannot s e e m to live without high-technology medicine; we cannot seem to
live amicably with it" [1]. The studied outward behavior of doctors when ministering to their patients has long been recognized and admired as an important "art form" in medicine. The performance is meant to reduce a patient's anxiety by demonstrating as much subjective concern for the person as objective interest in the presenting medical problem. And the doctor's convincing priestlike air of certainty in speech and in action is meant to persuade the patient to suspend all disbelief. Early in their schooling, medical students pick up on the importance of appearances, and imitate (often unconsciously) an admired friendly, but authoritative, "bedside manner." Budding doctors try to reproduce the facial expressions, poses, and tone of voice used by their most convincing role models. Unschooled (but not necessarily uncaring) frauds posing as doctors have performed successfully in medical settings, convincing patients and medical personnel completely and for surprisingly long periods of time, before they are unmasked. The image of the doctor as an authority but, above all, a dedicated friend was romanticized over 100 years ago by Sir Luke Fildes in his painting "The Doctor" [2]. It depicts a very distinguished-looking practitioner who has made a call at the cottage of what seems to be a poor family. He is shown sitting at the side of a deathly ill child lying on a makeshift bed set out on two chairs in a very dark, sparsely furnished room; the mother is standing, reverently, in the background. The doctor is leaning forward, chin cupped in hand; there is a kindly, puzzled expression on his face; it is easy to believe he is keeping a night-long vigil at the side of his dying patient. In the quiet scene, the medical profession is shown in its most endearing role, as the epitome of dedication and compassionate concern. When the painting was first shown in London, the artist's wife could not get near it because of huge crowds who came day after day to see the new piece in the art gallery. A photogravure copy of the painting became the most popular print ever issued by Agnew's,
Received May 20, 1991; revised July 22, 1991. Address reprint requests to: William A. Silverman, MD, 90 La Cuesta Drive, Greenbrae, CA 94804.
ControlledClinicalTrials13:97-99(1992) © ElsevierSciencePublishingCo., Inc. 1992 655 Avenueof the Americas,New York,New York10010
97
0197-2456/92/$5.00
98
W.A. Silverman a London printing firm. For many years, prints of the painting were seen hanging on walls in doctors' offices, in hospitals, in pharmacies, and in private homes all over the world. "The Doctor" was eventually reproduced on two postage stamps, and the image became familiar to millions of people as a symbol of the compassionate "art" of doctoring. John C. Burnham, a historian, has found that prior to the turn of this century, physicians in the United States were not always highly esteemed; they were often criticized for their pretensions and their greed [3]. However, the tide of public opinion shifted after medical, and particularly surgical, successes. The admirable image of the doctor was very much in evidence in the United States during the first half of the present century. Burnham has labeled this period "American medicine's golden age." Publicity about the profession became increasingly favorable. Burnham found that by the 1930s American doctors enjoyed considerable social prestige and were much admired for their work. Medicine came to be regarded as a model profession, he found that opinion polls from the 1930s to the 1950s consistently ranked doctors among the most highly admired persons, equal to or higher than supreme court justices. In 1952, an elderly doctor remembered that when he was young, the townspeople of Worcester, Massachusetts customarily tipped their hats to the physician as he passed by [4]. Although medicine was becoming increasingly effective in the first half of this century, Burnham notes that public attention was focused not so much on the profession's technical accomplishments, but on the individual doctor's "priestly" role. During the "golden age" there was preoccupation with a Fildes-like image of the doctor as a wise and trusted advisor. Though the "old-fashioned family doctor" was passing quickly from the scene, people seemed nonetheless to yearn for a warm personal relationship furnished by the idealized country practitioner. When criticisms about doctors began to mount in the 1950s, they reflected a continuing demand for personal attention rather than technical competence. The complaints about the indifference of doctors have become more frequent and have grown louder with the growth of specialization and the increasing complexity of treatments administered by groups of doctors practicing in hospital settings. The change in the form of doctoring since the turn of the century is, of course, striking: from the passive priestly model (a solo practitioner making a house call, sitting quietly at the bedside of a dying child) to the current hyperactive "engineering" model (a highly efficient team of medical experts in an intensive care unit working frantically to keep a deathly ill child alive with the full panoply of modern medical hardware). Doctors find it hard to understand the paradox: revered when they were relatively ineffectual, they now find themselves increasingly rebuked when they are able, for the first time ever, to change the expected course of so many disabling and fatal disorders. The burgeoning increase in medical knowledge holds the promise of ever more dramatic control of disease, yet the future is clouded if the beneficiaries continue to resist expansion of the limits of professional autonomy. It is of some interest to recall that during the early years of American medicine's golden age scientists' dreams about controlling biological processes were just beginning to grow. For example, at the end of the 19th century,
Doctoring: From Art to Engineering
99
Jacques Loeb was successful in achieving artificial parthenogenesis in sea urchin eggs, and he became convinced about the transformative potential of science [5]. During the years 1890-1915, Loeb was making strong claims about the power to control life. Biology in the 20th century should be organized around engineering aims, he proclaimed; the "engineer in biology" would no longer be satisfied with a quest for mere understanding, but was to be a man of action who used scientific insights to rule over nature. Echoes of the point of view that conflates medical science and technology can be detected in the ongoing struggle about the limits of doctors' actions. The disagreements reflect the failure to make a clear distinction between the store of scientific knowledge available at any given time, and the circumstances and conditions in which this knowledge is applied. Quite apart from what is purely technical and instrumental about medical practice, Freidson argues [6], there is embodied in it an inescapable moral element. The autonomy ceded to physicians to determine the content of medical work may be appropriate, he concludes, but a grant of the sole right to determine the practical modes of applying that knowledge cannot be justified. Is modern medicine responding to human need, critics want to know, or is it creating needs to which it responds?
REFERENCES 1. Rosenberg C. The Care of Strangers. New York, Basic Books, 1987 2. Trueherz J (Ed): Hard Times: Social Realism in Victorian Art. London; Lund Humphries, 1987 3. Burnham JC: American medicine's golden age: What happened to it? Science 215:14741479, 1982 4. Lundy JA: Arrow wounds. N Engl J Med 246:~! 446, 1952 5. Pauly PJ: Controlling Life. Jacques Loeb and the Engineering Ideal in Biology. Oxford, Oxford University Press, 1984 6. Freidson E: Profession of Medicine. New York, Dodd Mead, 1972