A Life in Medicine

by Robert Coles

  Fossils exist for both, making it possible to track back to somewhere near the beginning. The earliest forms of life were the prokaryotes, organisms of the same shape and size as bacteria; chains of cocci and bacilli left unmistakable imprints within rocks dating back as far as 3.5 billion years. Similar microorganisms comprised the total life of the planet for the next 2.5 billion years, living free or, more often, gathered together as immense colonies in “algal mats,” which later on fossilized into the formidable geological structures known as stromatolites. It was only recently, perhaps a billion years ago, that the prokaryotic algae had pumped enough oxygen into the earth’s atmosphere so that nucleated cells could be formed. The mitochondria, which provide oxidative energy for all nucleated cells, and the chloroplasts of plant cells, which engage the sun’s energy for producing the planet’s food and oxygen, are the lineal descendants of bacteria and blue-green algae, and have lived as symbionts with the rest of us for a billion years.

  The fossils of human language are much more recent, of course, and can only be scrutinized by the indirect methods of comparative philology, but they are certainly there. The most familiar ones are the Indo-European roots, prokaryote equivalents, the ancestors of most of the Western and some of the Eastern languages: Sanskrit, Greek, Latin, all the Slavic and Germanic tongues, Hittite, Tocharian, Iranian, Indic, some others, all originating in a common speech more than 20,000 years ago at a very rough guess. The original words from which the languages evolved were probably, at the outset, expressions of simple, non-nucleated ideas, unambiguous etymons.

  The two leeches are an example of biological mimicry at work in language. The root for leech the doctor goes back to the start of language: leg was a word meaning “to collect, with derivatives meaning to speak” and carried somehow the implication of knowledge and wisdom. It became laece in Old English, lake in Middle Dutch, with the meaning of doctor. Along the way, in early Germanic, it yielded lekjaz, a word meaning “an enchanter, speaking magic words,” which would fit well with the duties of early physicians. The doctor was called the leech in English for many centuries, and a Danish doctor is still known as Laege, a Swedish one as Lakere.

  Leg gave spawn to other progeny, different from the doctor but with related meanings. Lecture, logic, and logos are examples to flatter medicine’s heart.

  Leech the worm is harder to trace. The OED has it in tenth-century records as lyce, later laece, and then the two leeches became, for all practical purposes, the same general idea. Leech the doctor made his living by the use of leech the worm; leech the worm was believed (wrongly, I think) to have had restorative, health-giving gifts and was therefore, in its way, a sort of doctor. The technical term “assimilation” is used for this fusion of words with two different meanings into a single word carrying both. The idea of collecting has perhaps sustained the fusion, persisting inside each usage: blood for the leech, fees (and blood as well) for the doctor. Tax collectors were once called leeches, for the worm meaning, of course.

  The word doctor came from dek, meaning something proper and acceptable, useful. It became docere in Latin, to teach, also discere, to learn, hence disciple. In Greek it was understood to mean an acceptable kind of teaching, thus dogma and orthodox. Decorum and decency are cognate words.

  Medicine itself emerged from root med, which meant something like measuring out, or taking appropriate measures. Latin used med to make mederi, to look after, to heal. The English words moderate and modest are also descendants of med, carrying instructions for medicine long since forgotten; medical students ought to mediate (another cognate) from time to time about these etymological cousins.

  The physician came from a wonderful word, one of the master roots in the old language, bheu, meaning nature itself, being, existence. Phusis was made from this root in Greek, on its way to the English word physic, used for medicine in general, and physics, meaning the study of nature.

  Doctor, medicine, and physician, taken together with the cognate words that grew up around them, tell us a great deal about society’s ancient expectations from the profession, hard to live up to. Of all the list, moderate and modest seem to me the ones most in need of remembering. The root med has tucked itself inside these words, living as a successful symbiont, and its similar existence all these years inside medicine should be a steady message for the teacher, the healer, the collector of science, the old leech.

  Medicine was once the most respected of all the professions. Today, when it possesses an array of technologies for treating (or curing) diseases which were simply beyond comprehension a few years ago, medicine is under attack for all sorts of reasons. Doctors, the critics say, are applied scientists, concerned only with the disease at hand but never with the patient as an individual, whole person. They do not really listen. They are unwilling or incapable of explaining things to sick people or their families. They make mistakes in their risky technologies; hence the rapidly escalating cost of malpractice insurance. They are accessible only in their offices in huge, alarming clinics or within the walls of terrifying hospitals. The word “dehumanizing” is used as an epithet for the way they are trained, and for the way they practice. The old art of medicine has been lost, forgotten.

  The American medical schools are under pressure from all sides to bring back the family doctor—the sagacious, avuncular physician who used to make house calls, look after the illnesses of every member of the family, was even able to call the family dog by name. Whole new academic departments have been installed—some of them, in the state-run medical schools, actually legislated into existence—called, in the official catalogues, Family Practice, Primary Health Care, Preventive Medicine, Primary Medicine. The avowed intention is to turn out more general practitioners of the type that everyone remembers from childhood or from one’s parents’ or grandparents’ childhood, or from books, movies, and television.

  What is it that people have always expected from the doctor? How, indeed, has the profession of medicine survived for so much of human history? Doctors as a class have always been criticized for their deficiencies. Montaigne in his time, Molière in his, and Shaw had less regard for doctors and their medicine than today’s critics. What on earth were the patients of physicians in the nineteenth century and the centuries before, all the way back to my professional ancestors, the shamans of prehistory, hoping for when they called for the doctor? In the years of the great plagues, when carts came through the town streets each night to pick up the dead and carry them off for burial, what was the function of the doctor? Bubonic plague, typhus, tuberculosis, and syphilis were representative examples of a great number of rapidly progressive and usually lethal infections, killing off most of the victims no matter what was done by the doctor. What did the man do, when called out at night to visit the sick for whom he had nothing to offer for palliation, much less cure?

  Well, one thing he did, early on in history, was plainly magic. The shaman learned his profession the hardest way: he was compelled to go through something like a version of death itself, personally, and when he emerged he was considered qualified to deal with patients. He had epileptic fits, saw visions, and heard voices, lost himself in the wilderness for weeks on end, fell into long stretches of coma, and when he came back to life he was licensed to practice, dancing around the bedside, making smoke, chanting incomprehensibilities, and touching the patient everywhere. The touching was the real professional secret, never acknowledged as the central, essential skill, always obscured by the dancing and the chanting, but always busily there, the laying on of hands.

  There, I think, is the oldest and most effective act of doctors, the touching. Some people don’t like being handled by others, but not, or almost never, sick people. They need being touched, and part of the dismay in being very sick is the lack of close human contact. Ordinary people, even close friends, even family members, tend to stay away from the very sick, touching them as infrequently as possible for fear of interfering, or catching the illness, or just for fear of bad l
uck. The doctor’s oldest skill in trade was to place his hands on the patient.

  Over the centuries, the skill became more specialized and refined, the hands learned other things to do beyond mere contact. They probed to feel the pulse at the wrist, the tip of the spleen, or the edge of the liver, thumped to elicit resonant or dull sounds over the lungs, spread ointments over the skin, nicked veins for bleeding, but the same time touched, caressed, and at the end held on to the patient’s fingers.

  Most of the men who practiced this laying on of hands must have possessed, to begin with, the gift of affection. There are, certainly, some people who do not like other people much, and they would have been likely to stay away from an occupation requiring touching. If, by mistake, they found themselves apprenticed for medicine, they probably backed off or, if not, turned into unsuccessful doctors.

  Touching with the naked ear was one of the great advances in the history of medicine. Once it was learned that the heart and lungs made sounds of their own, and that the sounds were sometimes useful for diagnosis, physicians placed an ear over the heart, and over areas on the front and back of the chest, and listened. It is hard to imagine a friendlier human gesture, a more intimate signal of personal concern and affection, than these close bowed heads affixed to the skin. The stethoscope was invented in the nineteenth century, vastly enhancing the acoustics of the thorax, but removing the physician a certain distance from his patient. It was the earliest device of many still to come, one new technology after another, designed to increase that distance.

  Today, the doctor can perform a great many of his most essential tasks from his office in another building without ever seeing the patient. There are even computer programs for the taking of a history: a clerk can ask the questions and check the boxes on a printed form, and the computer will instantly provide a printout of the diagnostic possibilities to be considered and the laboratory procedures to be undertaken. Instead of spending forty-five minutes listening to the chest and palpating the abdomen, the doctor can sign a slip which sends the patient off to the X-ray department for a CT scan, with the expectation of seeing within the hour, in exquisite detail, all the body’s internal organs which he formerly had to make guesses about with his fingers and ears. The biochemistry laboratory eliminates the need for pondering and waiting for the appearance of new signs and symptoms. Computerized devices reveal electronic intimacies of the flawed heart or malfunctioning brain with a precision far beyond the touch or reach, or even the imagining, of the physician at the bedside a few generations back.

  The doctor can set himself, if he likes, at a distance, remote from the patient and the family, never touching anyone beyond a perfunctory handshake as the first and only contact. Medicine is no longer the laying on of hands, it is more like the reading of signals from machines.

  The mechanization of scientific medicine is here to stay. The new medicine works. It is a vastly more complicated profession, with more things to be done on short notice on which issues of life or death depend. The physician has the same obligations that he carried, overworked and often despairingly, fifty years ago, but now with any number of technological maneuvers to be undertaken quickly and with precision. It looks to the patient like a different experience from what his parents told him about, with something important left out. The doctor seems less like the close friend and confidant, less interested in him as a person, wholly concerned with treating the disease. And there is no changing this, no going back; nor, when you think about it, is there really any reason for wanting to go back. If I develop the signs and symptoms of malignant hypertension, or cancer of the colon, or subacute bacterial endocarditis, I want as much comfort and friendship as I can find at hand, but mostly I want to be treated quickly and effectively so as to survive, if that is possible. If I am in bed in a modern hospital, worrying about the cost of that bed as well, I want to get out as fast as possible, whole if possible.

  In my father’s time, talking with the patient was the biggest part of medicine, for it was almost all there was to do. The doctor-patient relationship was, for better or worse, a long conversation in which the patient was at the epicenter of concern and knew it. When I was an intern and scientific technology was in its earliest stage, the talk was still there, but hurried, often on the run.

  Today, with the advance of medicine’s various and complicated new technologies, the ward rounds now at the foot of the bed, the drawing of blood samples for automated assessment of every known (or suggested) biochemical abnormality, the rolling of wheelchairs and litters down through the corridors to the X-ray department, there is less time for talking. The longest and most personal conversations held with hospital patients when they come to the hospital are discussions of finances and insurance, engaged in by personnel trained in accountancy, whose scientific instruments are the computers. The hospitalized patient feels, for a time, like a working part of an immense, automated apparatus. He is admitted and discharged by batteries of computers, sometimes without even learning the doctors’ names. The difference can be strange and vaguely dismaying for patients. But there is another difference, worth emphasis. Many patients go home speedily, in good health, cured of their diseases. In my father’s day this happened much less often, and when it did, it was a matter of good luck or a strong constitution. When it happens today, it is more frequently due to technology.

  There are costs to be faced. Not just money, the real and heavy dollar costs. The close-up, reassuring, warm touch of the physician, the comfort and concern, the long, leisurely discussions in which everything including the dog can be worked into the conversation, are disappearing from the practice of medicine, and this may turn out to be too great a loss for the doctor as well as for the patient. This uniquely subtle, personal relationship has roots that go back into the beginnings of medicine’s history, and needs preserving. To do it right has never been easy; it takes the best of doctors, the best of friends. Once lost, even for as short a time as one generation, it may be too difficult a task to bring it back again.

  If I were a medical student or an intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be trying to figure out ways to keep this from happening.

  Mikhail Bulgakov

  BAPTISM BY ROTATION from A Country Doctor’s Notebook

  After graduating from medical school, Mikhail Bulgakov spent the next eighteen months in an isolated, rural area of Russia. This story reflects the new practitioner’s uncertainty and the challenge of moving from book knowledge to practical knowledge. Although he feels isolated and timorous, he has no choice as a doctor but to treat the woman who has been brought to his hospital in the throes of a difficult labor. He takes what is offered by the midwife, then retreats for a hasty consultation with his text. When he completes the procedure (with a positive outcome), he reflects on the need to “engage in lifelong learning.”

  MIKHAIL BULGAKOV (1891–1940) graduated from medical school at Kiev University in 1916. After practicing for a decade, Bulgakov became a full-time writer. A Country Doctor’s Notebook, from which this story was taken, was first published in 1925–27. Bulgakov is also the author of the modern masterpiece The Master and Margarita.

  As time passed in my country hospital, I gradually got used to the new way of life.

  They were braking flax in the villages as they had always done, the roads were still impassable, and no more than five patients came to my daily surgery. My evenings were entirely free, and I spent them sorting out the library, reading surgical manuals and spending long hours drinking tea alone with the gently humming samovar.

  For whole days and nights it poured with rain, the drops pounded unceasingly on the roof and the water cascaded past my window, swirling along the gutter and into a tub. Outside was slush, darkness and fog, through which the windows of the
feldsher’s house and the kerosene lantern over the gateway were no more than faint, blurred patches of light.

  On one such evening I was sitting in my study with an atlas of topographical anatomy. The absolute silence was only disturbed by the occasional gnawing of mice behind the sideboard in the dining room.

  I read until my eyelids grew so heavy that they began to stick together. Finally I yawned, put the atlas aside, and decided to go to bed. I stretched in pleasant anticipation of sleeping soundly to the accompaniment of the noisy pounding of the rain, then went across to my bedroom, undressed, and lay down.

  No sooner had my head touched the pillow than there swam hazily before me the face of Anna Prokhorova, a girl of seventeen from the village of Toropovo. She had needed a tooth extracting. Demyan Lukich, the feldsher, floated silently past holding a gleaming pair of pincers. Remembering how he always said “suchlike” instead of “such” because he was fond of a highfalutin style, I smiled and fell asleep.

  About half an hour later, however, I suddenly woke up as though I had been pinched, sat up, stared fearfully into the darkness and listened.

  Someone was drumming loudly and insistently on the outer door and I immediately sensed that those knocks boded no good.

  Then came a knock on the door of my quarters.

  The noise stopped, there was a grating of bolts, the sound of the cook talking, an indistinct voice in reply, then someone came creaking up the stairs, passed quietly through the study and knocked on my bedroom door.

  “Who is it?”

  “It’s me,” came the reply in a respectful whisper. “Me, Aksinya, the nurse.”

  ‘What’s the matter?’

  “Anna Nikolaevna has sent for you. They want you to come to the hospital as quickly as possible.”