CHAPTER 1
Persistent Problems of Medicine
I
In 1928, when I entered medical school, our class was fully aware of the great ferment taking place in medicine. Insulin had only recently been discovered, and so had the curative value of liver in pernicious anemia. Endocrinology was emerging as an active discipline. The important role that electrolytes played in health and disease was receiving abundant study. Protein chemistry was making great progress, as was immunology. Surgical interventions were becoming more and more dramatic. By the time we graduated we were fully convinced that the medicine of our day was a truly scientific discipline and that it contrasted markedly with the empirical approach that had prevailed in the previous generation.
In the medical records that we wrote as students we would note the diagnoses and treatment that the patient might have received earlier from his family physician. We referred to this family doctor as the LMD — the local physician of the community, in contrast to the hospital-based physician — and we implied, condescendingly, that before the patient came into our hands he had been subjected not to scientific study but only to blundering guesswork. In the exuberance of youth we had little appreciation of the real problems of medicine.
The years passed swiftly. During World War II we were the young well-trained physicians, ten years out of school, rapidly becoming leaders in the profession. The book learning we had acquired seemed to remain essentially valid, and our theories had been tempered by considerable practical experience. During the war, and for a brief period thereafter, we enjoyed a sense of mastery that we would never feel again.
Our own training had taken place during economic depression, when research was receiving only limited support, and during war years, when research was more practical than theoretical. Then, after the war, medicine acquired a new momentum that increased at a frightening rate. For a long time the physicians of my generation could keep up in our own specialties and even contribute to their advancement. But as the years passed the over-all changes in both theory and practice forced each of us deeper into his own niche of specialization. And from our limited positions we could see a tidal wave of progress — new technology, new theory, new practice — engulfing the medical world. Younger men were taking over leadership. The years passed more and more rapidly until at length the members of my own generation could, if lucky, assume the status of elder statesmen in medicine. If not so lucky they acquired the status of old fuddy-duddy, regarded by the new bright young men just as we had regarded the LMD who had graduated in 1905 or 1910.
The great rush of progress produced the viewpoint that modern medicine differed markedly from that of the past, and that only now, in what we may call the electronic age, was medicine at last really scientific. And the questions arose: When did this transformation take placer When did medicine become truly modern, truly scientific? In 1932 my own generation thought that it had all the answers, but now the new generations of physicians, together with the students they taught and the lay public they indoctrinated, all had a different set of answers. The very brash would say that only for the past ten years was medicine truly scientific, the more conservative would say twenty or twenty-five years. But there was general agreement that what took place more than twenty-five years ago was no longer part of current medicine but belonged rather to medical history. And what took place before World War II held only archeological interest for the medical student or resident. The general public tended to follow this belief.
This attitude was being continually reinforced by well-meaning deans and medical educators who would emphasize the transitory nature of medical education. In effect, these prophets said, of all the information learned today, approximately half would be obsolete within five years. Hence the catchy phrase, that the "half-life" of medical knowledge is a scant five years. Some optimists (or were they pessimists?) might extend the limit to as much as eight years.
Such concepts gave a vivid sense of tumultuous progress and appealed to the popular imagination. But for medical students this was a rather discouraging thought and for many of the older physicians twenty-five years out of school it was a shattering prospect indeed. But what does such facile generalization about medicine really mean? How much change have we actually had? Before we accept at face value all the publicity that medicine receives, we should study the presuppositions that inhere in the concept of medical progress.
The lay public shows a great curiosity about medical progress. Many newspapers and popular journals have special editors who ferret out the new discoveries and present the gist in suitable lay language. A constant stream of books and articles tells the public about the latest advances in medicine. To such lengths has popularization gone that physicians in practice occasionally complain that their patients, after reading popular magazines, may know more about new remedies than they themselves do.
This lay interest in health matters can distort our perspective. A succession of "breakthroughs," enthusiastically reported in the press, can lead the public to expect continued breakthroughs; and journalists looking for copy and not wanting to disappoint their public may magnify the importance of new medical reports. As a result, progress may seem to be greater than it actually is. Publicity may inflate significance.
Other factors may contribute to this inflation. Fund raising for medical research is big business, and fund raising thrives better when new advances seem imminent-hence the temptation to exaggerate the significance of new findings. Then, as a correlative, institutions that seek research support may sometimes encourage publication before conclusions are fully established. And, among individual researchers, the race for priority may induce premature publication or exaggerated claims. Without laboring the point I suggest that important advances may not be as numerous as we may at first think.
Yet, even after allowing for exaggeration and inflated importance, we must stand in awe at the changes that have taken place in medicine in the past twenty-five years. They affect all modalities. We have new modes of...
