Hillary Johnson on the decline of clinical medicine and the role of patient observation in medical practice
‘To get an accurate knowledge of any disease it is necessary to study a large series of cases and to go into all the particulars – the conditions under which it is met, the subjects specially liable, the various symptoms, the pathological changes, the effects of drugs … in the faculty of observation, the old Greeks were our masters, and we must return to their methods if progress [is] to be made.’
‘The greater the dogmatism, the greater the ignorance.’
‘There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.’
 Sir William Osler, Counsels and Ideals 1905
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From Hillary Johnson OSLER’S WEB: Inside the Labyrinth of the Chronic Fatigue Syndrome epidemic (Crown Publishers, New York, 1996) pp. 128-9
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During the [early] decades [of the twentieth century] … clinical medicine was ascending in importance and prestige, due in great part to the Canadian clinician Sir William Osler, who lived from 1849 to 1919 and who taught medicine to students in Canada, the United States, and at the time of his death, England.* Osler’s international eminence derived from his descriptive and diagnostic gifts. He defined the sign and symptom complexes of many of the most perplexing, obscure diseases of his era, favoring the substitution of observation and method for speculation and theory. In short, Osler believed in listening to the patient. In the course of his luminous career, he became a prolific lecturer and essayist, frequently extolling the virtues of meticulous clinical observation. He knew that the conservative nature of his profession often blinded it to the obvious. And he exhorted his medical students to be on guard against lockstep thinking.
In the decades after his death, Osler’s diagnostic ideals began to be supplanted by the rise of medical technology. Like a shifting of the stony plates beneath the earth’s surface, technology’s force transformed the clinical landscape. Cognitive medicine, the art of divining and interpreting the nature and source of illness, lost ground to the laboratory bench. One bug, and one bug alone, caused each disease, according to the microbe hunters, and scientists seemed to be closing in rapidly on ways of identifying every bug. In time, blood tests emerged for several of the major infectious diseases, including syphilis, tuberculosis, gonorrhea, rabies, and typhoid. These developments were an undeniable boon, ending untold cycles of suffering, but they began subtly to erode the tradition of “well and complete” observation extolled by Osler. Once the spirochete at its source could be isolated, the degree of clinical skill required to recognize syphilis, for instance, a disease with mutable, elusive signs and symptoms ranging from lesions to lunacy, receded.
For an ailment like the one afflicting people in northern Nevada, California, and elsewhere – an ill-defined disease lacking a single, indisputable marker – technology alone offered ambivalent relief; technology needed to be harnessed, much in the manner of Paul Cheney and Dan Peterson, by clearheaded clinicians who favored Osler’s style of scrupulous clinical observation. Cheney, in addition, brought a physicist’s ebullient creativity to the dilemma, a contribution, it might be added, his conservative critics in medicine distrusted profoundly.
By the early 1980s, half a century after Osler’s death, the breach between doctors in private practice and clinician-researchers in academia was gaping. Michael Gottlieb, an assistant professor at UCLA from 1980 to 1987 and the first research clinician to describe AIDS as a coherent disease entity, elaborated on the phenomenon during a conversation in Santa Monica in 1988.
“A misconception that clinical observation does not lead to new knowledge prevails widely in academic medicine today,” Gottlieb said. “There is a widespread view that the age of seminal clinical observation is over and that the only progress now will be through the laboratory. Certainly I will be among the first to point to the successes of laboratory investigation since the early part of this century. There has been dramatic progress. However, occasionally something very important of a clinical nature is observed and can lead to further breakthroughs,” Gottlieb continued. “That was the case with AIDS. It could be the case with other conditions.”
Gottlieb was thirty-two and a freshly trained immunologist when he began his UCLA career. In 1982, using the government’s Morbidity and Mortality Weekly Report as his vehicle, he filed the first scientific report on AIDS, describing five cases of young, previously healthy men who had T -cell deficiencies and had died of an extremely rare disease: Pneumocystis carinii pneumonia. Gottlieb’s colleagues at UCLA failed to reward him for his effort, Many, in fact, advised him to turn his energies toward a more “legitimate” area of medical research. By 1987, Gottlieb had been denied tenure three times, even though his research ultimately had secured his university a $10.2 million AIDS research grant. There was gossip that the academicians who had prevented his tenure would blackball him at other university labs. In 1987, Gottlieb, who had foreseen for himself a research career in academia, opened a private clinical practice of immunology in Santa Monica. He placed much of the blame for his loss of favor among the UCLA faculty on the overtly clinical orientation of his research. “The moral of the story is, I suppose, if you’re going to make brilliant observations, be sure that they’re in the laboratory,” he continued. “And do steady, inconspicuous work until you have tenure. Academia breeds small minds,” he added. “It’s rare that the truly brilliant, insightful person survives. The system selects for mediocrity.”
* [Note added by RW] William Osler was, successively, a professor of medicine at McGill University, Canada, at the University of Pennsylvania and at the John Hopkins University Hospital, Baltimore. In 1905 he was appointed to the Regius Chair of Medicine at the University of Oxford. He lived at 13 Norham Gardens where he and his wife entertained countless distinguished visitors including Rudyard Kipling and Mark Twain. It has been said of him that ‘he had more influence on the practice of modern medicine than any other individual in this and the last century.’ For ‘Sir William Osler’s Emphasis on Physical Diagnosis and Listening to the Patient’ by Billy F. Andrews (from the Southern Medical Journal, 95(10):1173-1177, 2002 , click
here. For the Green College page on Osler in Oxford, click here).] |
