A piece of my mind: a new collection of essays from JAMA Roxanne K. Young, editor American Medical Association Press, Chicago; 2000 332 pp. US$34.00 ISBN 1-57947-082-3
As Robert Bly recounts it,1 the Japanese, whose society has honoured the warrior for centuries, tell a story about a pond that had lost its king; uncertain about what to do, the pond's inhabitants finally elect a heron (an emblem of the warrior) to be king. The problem with this arrangement soon becomes apparent: the heron eats up everyone in the pond.
Sometimes in the moments before I doze off in research rounds, stymied by signals, mesmerized by messengers and numbed by Northern blots, I wonder if the herons have taken over medicine. But any such notion may be dispelled by reading A Piece of My Mind, a collection of essays from the Journal of the American Medical Association.
These essays are a beautiful set of epiphanies about the human side of medicine. There is the junior student sent to draw blood from a baby who was burned in a home fire. The child is horribly burned, difficult to draw blood from and suffering terribly from repeated medical interventions. After many attempts the student succeeds in drawing the blood and tries to leave the room. He has been trying to leave ever since.
There is the wife of the cancer patient who allows him to order her to stand in a corner when they have a disagreement. As she says, “We both know it's a macabre charade, but I go there happily to restore a smidgen of his lost power.”
There is a story called “A mutual investment company” in which a woman going for a routine Pap smear expresses her appreciation for her physician, Dr. Goodwin, who takes time, listens to her and treats her like a human being. She concludes, “Thank you for investing in me. Please know that I have invested in you too.”
There is not a story in this collection that did not touch me. Perhaps the ethos of these short pieces is best summed up in a story called “Last rounds,” in which a physician watches his physician-father die of lung cancer. The writer concludes, “Medicine is still very much alive, but it lives not so much in the frontiers of the new technology, which too often only painfully prolongs the entrance of death, as in the hearts of physicians.” Perhaps he could also have added: “in the hearts of nurses and other health care workers, and particularly in the hearts of patients.”
But, despite the reassurance I derive from this book, I begin to worry again. I think I can see, or I fear, where the herons of molecular biology might lead us. They have a vision of achieving complete victory over human disease by understanding exactly how the body works as a machine, from genetic code to the details of subcellular functioning. They have a program and the technology necessary to implement it. Who can enunciate a vision that is clear, comprehensive, simple and inspiring for the whole of medicine, including its human side: a vision that is neither arrogated by technology nor the equivalent of motherhood and apple pie for everyone? We need a plan that incorporates our humanity and is oriented to the future. Most important, all aspects of such a plan must be subject to the scientific method of testing hypotheses and learning the most when our predictions are proved wrong.2 Can we really test predictions about the long-term effects of kindness? Without that we may feel that we are doing good but we might just be fooling ourselves. Can we really know that Dr. Goodwin's investment in his patient paid any important dividends other than making him late for research rounds?