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The Patient and the Man
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                               The Patient and the Man
                           (Presented by Francis W. Peabody, MD before the New

                                                     York Academy of Medicine, November 22, 1922)       

 

       How deep a satisfaction we who style ourselves “Internists” derive from the fact that we live in an era of “scientific medicine.”   We realize, of course, that the time has not yet come when clinical medicine can rank as a pure science, but we have already reached the stage where we apologize to our students and even to our patients for the use of methods that are merely empirical, and we seem to be on safe and dignified ground only when we are dealing with facts that are capable of objective demonstration.  The application of the methods of science to the practice of medicine has in two short generations led us so far out of the wilderness of tradition and superstition that we long for the time when we shall reach that promised land in which disease may be dealt with on a wholly rational basis. We cherish the idea that the redemption of medicine is to come through science—and we are very contented to have brought our calling so far along the way to salvation.
     But now that we have reached a point of vantage, is it not well for us to pause and consider what progress has actually been made and whether the pathway of applied science is, after all, the only one along which clinical medicine must proceed?  As investigators we may work intensely in any of the fields that border clinical medicine, but as physicians and teachers we must follow the road that leads to the broadest view of medicine practice.
     There can be no discussion as to the outstanding contribution which has been made to clinical medicine by the application to it of the so-called fundamental medical sciences. The only point that may be raised is as to whether our zeal for the application of scientific methods may not have drawn us into the somewhat anomalous position where we have been carried away from much that is good but unscientific, and at the same time are still not quite so near to our scientific ideal as we like to  think.  Are we, perhaps, in danger of overestimating the absolute value of some of our new technical advances? Take, for instance, the matter of the objective study of patients by laboratory procedures and the general tendency to substitute instrumental methods of examination for the comparatively crude senses of even the trained physician.
     Theoretically, it is only intended that they should supplement the physical examination, but practically, we know how quickly the students—and we ourselves, forthat matter—turn to the laboratory to solve our problems, with implicit faith in the results. X-ray, basal metabolism, electrocardiograph, blood pressure determinations—these are the things that count. Such observations are usually considered to represent accurate, objective scientific experiments. But do they? Are they not often very unscientific experiments?  In the scientific experiment of the chemist or the physiologist, the various factors which contribute to the outcome are to a large extent known and controlled—the conditions are fixed from experiment to experiment.  In man this is frequently impossible. We count the pulse or we register the blood pressure and write down the figures with considerable satisfaction at being able to use a mathematical representation. It savors of a scientific experiment. But all the time we are apt to forget that it may be a very uncontrolled experiment, and that we are entirely neglecting one of the most important factors in influencing the results.
    The test tube has no central nervous system and the decerebrate cat has no emotional life, but in man, the nervous system and its emotional reactions dominate every phase of his existence and influence to some unknown extent a considerable proportion of our observations and experiments. It is this factor that we so frequently neglect—the man himself, the sick human with all his complex emotions toward the world and toward himself, and the effects of these emotions on his disordered functions. Our fathers knew less of disease but more of men, and, if we do not take care, our successors are liable to know much about disease but very little about human beings. The students of today write  page after page of record telling in minute detail everything from the cause of death of the patient’s grandmother to the curious sensations the patient once had in is toes, but when it is all finished how much do they know about the man himself, about the kind of personality they are dealing with?  How often do they consider the effect of his nervous system on the blood pressure reading?
     Every good general practitioner knows consciously or subconsciously the nervous make-up of his patients and  realizes that this make-up influences the course of their disease. We who specialize in internal medicine, however, are apt to divide cases somewhat categorically into the two groups of organic and functional disease, and whenwe are dealing with the former we are inclined to focus our attention almost exclusively on the objectively demonstrable evidences of pathology. We may appreciate dimly the fact that the personality of the patient affects the course, if not the outcome, of the disease, but our interest in the observation of measurable and demonstrable facts which can be interpreted in the light of the fundamental sciences, frequently makes us neglect this somewhat intangible aspect of the case. And yet how often we see a patient with organic heart disease in whom the essential problem of adjustment to life is to be solved, not by auscultation or electrocardiography or by the scientific administration of digitalis, but rather by an understanding of the personality and by helping a confused and worried mind to adapt itself smoothly to a new and difficult existence. We may make and record a mass of accurate observations about our patients and yet we may miss the point of the case entirely.
     Sometimes—and here the “specialists” are perhaps most often at fault—the organic lesion is very slight, so slight as to be scarcely recognized save by the expert eye, and yet it is made to account for a whole chain of distressing functional disturbances. Who has not seen the woman with the painful back—the back that on general physical examination looks normal and moves normally, but to the specialist presents a little deviation that seems to warrant weeks of rest and a plaster cast. In due time the plaster straightens out the little twist in her spine, but meanwhile the big kinks in her life, which might well give her a pain not only in her back but in her whole body, remain unnoticed and unrelieved. The little organic lesion has dominated the picture, but the true diagnosis has been missed. It was not “back-strain” but “life-strain.”
     As internists our whole training leads us to explain every possible symptom on an organic basis and we carry this so far that if we find no obvious simple cause, we follow the latest fashion and cloak our ignorance by turning to the broad and unexplored wilderness of so-called “endocrinology” where, in the name of science (!) we , find a theory to fit the case. So absorbed have we been in increasing our knowledge of the material aspects of disease that our instinct is to interpret all sickness in terms of an organic lesion and we neglect the existence of the great determinant, man’s mental life. But it is there, withal, and it brings hard problems for the internist. On the one hand, he is harassed by the problem of the recognition of the symptoms and signs of important organic disease in its very earliest stages, and on the other hand, by that of the differentiation of symptoms caused by an emotional disturbance and reflected in some
remote area of lowered resistance. Diagnostic error may be almost equally serious in either instance, for in one it may lead to death, and in the other to perhaps even more distressing life. Wisdom and experience are necessary and all the information that applied science can contribute must be at hand, but in addition there must  be a clear appreciation of the diverse ways in which emotional reactions may manifest themselves and an understanding of the personal life of the patient. It is only when the organic factors and the emotional factors have been studied and balanced that the proper therapeutic measures can be applied. 
      In one type of case—in the clear cut neuroses and psychoses, the role of personality and emotional life is generally accepted, but in these patients the internist is apt to manifest but little interest. In the wards and in the Dispensary much attention is paid to the study of an aneurysm or a carcinoma of the liver, but when the intern says “this is a gastric neurasthenic; he does not show anything” the visit hurries by to the next bed where a man with heart failure presents more stimulating problems for discussion. The interns and the students quickly come to regard the gastric neurasthenic as an unimport-ant bore who is to be hurried through his examination and discharged with the cold comfort to be derived from being told he has nothing the matter with him. Of course he has something the matter with him—something that  may be very distressing and very incapacitating, even though we can find no objective evidence of its cause, and our frequent failure to be concerned about his condition is hardly in keeping with good medical practice.
     But, apart from this, even, is our attitude the right one? One group of patients is suffering from incurable organic disease and the problem is to prolong life a little and make it easier; the other group will live indefinitely,  and either its members will live miserable, useless lives or, if they can be cured, will live useful, happy lives. Do they not, after all, present an equally important, an equally stimulating problem? It is no brief or easy task to ferret out the experiences in life that have induced the symptoms, to clear the confused ideas, and lead the patient to look at himself and the world simply and straight, but the possible result will justify the additional attention. Here is a condition that can be cured, and for the cure the physician can take full credit. Perhaps it may be contended that these patients belong to the psychiatrist and not to the internist and that students must learn to treat them in the neurological department. Such an artificial segregation, however, is not warranted. It is in the general medical wards that interns and students must get their preparation for the general practice of medicine, and in general medical practice the functional disturbances of the nervous system, with their complex relations to varying degrees of somatic disease in other parts of the body, play an important part. There were no less than twenty such cases among the last one hundred patients in my own practice.
     Our duty is not to avoid the issue or lay the burden on the psychiatrist, but to accept it as a part of the field of internal medicine, and to try to instruct our students as to its significance and as to the satisfaction to be gained from its successful management.   In many instances of functional disturbance of the nervous system, the internist has a distinct advantage over the psychiatrist, for a painstaking examination involving the use of all scientific methods for the study of disease is a prerequisite to successful treatment. This is best performed by the internist who is trained in the use and interpretation of  these methods and then, fortified by the results of his examination, he is in a strong position to carry on the proper therapy. Undoubtedly, he is greatly helped by having something of the point of view of the psychiatrist and a little of the newer technic of psychiatry, but he should handle the patient as a practitioner of medicine.  Individual cases are, of course, too obscure for him and  require the assistance of the specially qualified psychiatrist, but the great majority of instances should be and can be entirely satisfactorily cared for by the internist who recognizes the type of problem.
     This is the crux of the situation, for failure to recognize the influence of emotional causes on the production of symptoms referable to remote organs leads to a therapy directed to the organ itself and this in turn perpetuates the symptoms. Many are the gastric and cardiac neurasthenics whose pitiable lives are to be laid at the door of some physician who failed to see the problem. The great clinicians of the Older School knew, as by intuition, how to distinguish those who were sick in spirit from those who were sick in body, and by the power of their personality could cure them. To us, of smaller stature, new methods and new tools have been given so that we too may solve the problem if we but see it straight.
     Chemistry, physiology, psychology—these and other sciences are making the found-ations of medicine stronger from year to year, but medicine itself can never become merely an applied science. The proper employment of the fundamental sciences in the study of disease has become an essential for good medical practice, but over and above this, there must be something which correlates the scientific findings with the actual problems of the individual case—the art of medicine, which carries us beyond the patient to the man.    

 

Reprinted from: Oglesby Paul, The Caring Physician.