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Medicine as a black box
DISSECTING ROOM
LIFELINE Medicine as a black box
Sofia Gruskin Sofia Gruskin is an associate professor in the Department of Population and International Health, and Director of the Programme on International Health and Human Rights of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard School of Public Health, Boston, MA, USA. The emphasis of her work is the implications of linking health to human rights, in particular for women, children, gender issues, and vulnerable populations in the context of HIV/AIDS. Which event has had most effect on your work, and why? The emergence of HIV/AIDS in San Francisco in the early 1980s has had the greatest effect on my work. First the impact on my close circle of friends and then the devastating effects globally. What would be your advice to a newly qualified doctor? Pay attention to the promotion and protection of human rights as they are a powerful medicine. What is the best piece of advice you have received, and from whom? My colleague Daniel Tarantola told me “as an author violate your deadlines freely because the editor is always lying. And as an editor continue to pretend the deadlines you set are inviolable.” What is your greatest fear? That politics and ideology replace reason and science as a basis for public health decision making. What is your worst habit? Stealing pens from other people’s desks or dropping paper clips on carpets and not picking them up. It’s a toss up. Do you believe in capital punishment? I believe capital punishment is a disgrace to humanity. Do you apply subjective moral judgments in your work? No; but I find it unfortunate that the assumption in health and medical circles is often that human rights are nothing but that. If you had not entered your current profession, what would you have liked to do? To be responsible for lighting architectural monuments. What was the most memorable comment you ever received from a referee? I liked your piece but would advise you to work harder towards becoming a specialist in lighting architectural monuments.
1408
he problem with medicine is that we know too much. Diagnosis has become a matter of wading through the evidence base and ordering the relevant tests. There is little challenge any more, little excitement, and naturally many doctors are secretly becoming a little bored with their profession. I was therefore pleasantly surprised recently while “entertaining” a few preclinical students in the operating theatre. They were spending some days in the hospital to get a taste of clinical medicine. “OK”, I said to the first student as she strained to peer through the microscope in the middle of the operation, “tell me all about the chorda tympani and what it does”. “We have no idea”, her colleague answered for her, “We do not get anatomy during our studies any more”, she added almost too complacently. I was irritated at first, thinking they had discovered a cunning way out of an awkward question, but as I grilled them further on various aspects of anatomy, I discovered that they were in earnest; they really had no idea. They listened attentively, enthusiastically hazarding wild guesses. Suddenly I was struck by the simple brilliance of the concept. Medicine need never be boring again! If you have no more than the vaguest knowledge of what lies under the surface, your career is bound to be filled with exciting speculation whenever a patient presents with a complaint. I could not help wondering in admiration which member of the university teaching committee had come up with the idea, and how on earth they had managed to get the plan past the rather conservative professorial body. Surely the anatomists must have put up a fight to defend their territory, the surgeons might have complained, even the internists would have been disconcerted. We will probably never know the exact details of what must amount to a subtle
T
academic coup, for the university organisation is still very much medieval and hermetic in its set-up. Even the academic staff appointments are an utter mystery; although I have been told that a thin column of smoke rising at dawn from one of the university chimneys on the first Tuesday of even months might signify that a new head of department has been instated. I wonder if there are plans to extend the programme, for, if you examine it closely, the possibilities are endless. We could start by not teaching students any physiology either, or pathology, or pharmacology, and so increase the uncertainty of medical practice still further; the true black box approach to medicine. It might be an idea to randomise the groups to whom particular basic subjects are not taught at all, so the experiment becomes truly scientific. You would have to be careful with future choices of specialisation, so that you do not accidentally teach anatomy to the budding surgeon or physiology to a future internist and thus ruin the project. Gradually, with experience, the patient would be converted into a fascinating patchwork of arbitrarily acquired knowledge; a kind of surrealist homunculus with specialist bias; well developed in his or her specialty and almost vacant in others. There is an additional hidden benefit in that it should soon be possible to reduce the length of medical training considerably, and train more doctors in the same time span, thus solving not only problems with boredom and burnout, but also the chronic staff shortages now plaguing the health services of many European countries. Almost inevitably there might be an initial slight decline in quality of medical care, but I am certain that this will be richly compensated for by the increased placebo effect of enthusiastic physicians. Johannes Borgstein
THE LANCET • Vol 363 • April 24, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.
LIFELINE Medicine as a black box
Sofia Gruskin Sofia Gruskin is an associate professor in the Department of Population and International Health, and Director of the Programme on International Health and Human Rights of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard School of Public Health, Boston, MA, USA. The emphasis of her work is the implications of linking health to human rights, in particular for women, children, gender issues, and vulnerable populations in the context of HIV/AIDS. Which event has had most effect on your work, and why? The emergence of HIV/AIDS in San Francisco in the early 1980s has had the greatest effect on my work. First the impact on my close circle of friends and then the devastating effects globally. What would be your advice to a newly qualified doctor? Pay attention to the promotion and protection of human rights as they are a powerful medicine. What is the best piece of advice you have received, and from whom? My colleague Daniel Tarantola told me “as an author violate your deadlines freely because the editor is always lying. And as an editor continue to pretend the deadlines you set are inviolable.” What is your greatest fear? That politics and ideology replace reason and science as a basis for public health decision making. What is your worst habit? Stealing pens from other people’s desks or dropping paper clips on carpets and not picking them up. It’s a toss up. Do you believe in capital punishment? I believe capital punishment is a disgrace to humanity. Do you apply subjective moral judgments in your work? No; but I find it unfortunate that the assumption in health and medical circles is often that human rights are nothing but that. If you had not entered your current profession, what would you have liked to do? To be responsible for lighting architectural monuments. What was the most memorable comment you ever received from a referee? I liked your piece but would advise you to work harder towards becoming a specialist in lighting architectural monuments.
1408
he problem with medicine is that we know too much. Diagnosis has become a matter of wading through the evidence base and ordering the relevant tests. There is little challenge any more, little excitement, and naturally many doctors are secretly becoming a little bored with their profession. I was therefore pleasantly surprised recently while “entertaining” a few preclinical students in the operating theatre. They were spending some days in the hospital to get a taste of clinical medicine. “OK”, I said to the first student as she strained to peer through the microscope in the middle of the operation, “tell me all about the chorda tympani and what it does”. “We have no idea”, her colleague answered for her, “We do not get anatomy during our studies any more”, she added almost too complacently. I was irritated at first, thinking they had discovered a cunning way out of an awkward question, but as I grilled them further on various aspects of anatomy, I discovered that they were in earnest; they really had no idea. They listened attentively, enthusiastically hazarding wild guesses. Suddenly I was struck by the simple brilliance of the concept. Medicine need never be boring again! If you have no more than the vaguest knowledge of what lies under the surface, your career is bound to be filled with exciting speculation whenever a patient presents with a complaint. I could not help wondering in admiration which member of the university teaching committee had come up with the idea, and how on earth they had managed to get the plan past the rather conservative professorial body. Surely the anatomists must have put up a fight to defend their territory, the surgeons might have complained, even the internists would have been disconcerted. We will probably never know the exact details of what must amount to a subtle
T
academic coup, for the university organisation is still very much medieval and hermetic in its set-up. Even the academic staff appointments are an utter mystery; although I have been told that a thin column of smoke rising at dawn from one of the university chimneys on the first Tuesday of even months might signify that a new head of department has been instated. I wonder if there are plans to extend the programme, for, if you examine it closely, the possibilities are endless. We could start by not teaching students any physiology either, or pathology, or pharmacology, and so increase the uncertainty of medical practice still further; the true black box approach to medicine. It might be an idea to randomise the groups to whom particular basic subjects are not taught at all, so the experiment becomes truly scientific. You would have to be careful with future choices of specialisation, so that you do not accidentally teach anatomy to the budding surgeon or physiology to a future internist and thus ruin the project. Gradually, with experience, the patient would be converted into a fascinating patchwork of arbitrarily acquired knowledge; a kind of surrealist homunculus with specialist bias; well developed in his or her specialty and almost vacant in others. There is an additional hidden benefit in that it should soon be possible to reduce the length of medical training considerably, and train more doctors in the same time span, thus solving not only problems with boredom and burnout, but also the chronic staff shortages now plaguing the health services of many European countries. Almost inevitably there might be an initial slight decline in quality of medical care, but I am certain that this will be richly compensated for by the increased placebo effect of enthusiastic physicians. Johannes Borgstein
THE LANCET • Vol 363 • April 24, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.