The Youngest Science
Author: Lewis Thomas
What is right with healthcare, what has gone wrong with it, and what can be done to fix it? These are the questions this perceptive observer of medicine raised and answered in this book. Although he practiced as a physician almost a century ago, his synoptic perspective of healthcare is as relevant today as it was then. He started with an assessment of the practice of medicine at the beginning of the 20th century, a time he said the vocation was just an ‘art of prediction‘ that was symbolised by ‘therapeutic nihilism‘, and ‘for all its facade as a learned profession, was in real life a profoundly ignorant occupation‘. He then charted the evolution of the specialty to the late 1930’s when it became ‘a technology based on genuine science‘, and when it offered effective treatments. The book’s exceptionally profound insights and recommendations cover such diverse subjects as medical training and practice, healthcare research and management, and the fractious relationship between nurses and doctors (pages 19-20, 27-28, and 31-43).
The book’s central theme is perhaps best captured by the author’s concerns about the progressively declining status of medicine as a profession. He observed that medicine, ‘the most respected of all the professions’, had come ‘under attack for all sorts of reasons’, and he thought the most damaging of these was the charge that doctors were ‘concerned only with the disease at hand but never with the patient as an individual, whole person’. He regretted that the public have come to perceive doctors as people who don’t listen or explain sufficiently, are inaccessible, and are error-prone. The author attributed this increasing distance between physicians and their patients to the progressive ‘mechanization of scientific medicine‘ as illustrated by the way that the stethoscope and succeeding technologies have replaced the physician’s touch, something he portrayed variously as ‘the oldest and most effective act of doctors’, their ‘essential skill’, and ‘the real professional secret‘. The author explored the divide where on one side are the patients – ailing people who have a deep need to be touched because ‘part of the dismay in being sick is the lack of close human contact‘ – and on the other side are the doctors – healers who are progressively unable to touch their patients because of the technologies that have come to dominate their diagnostic and therapeutic tasks (pages 52-57).
Whilst the author recognised the adverse impact of technology on the patient-doctor interaction, he was nevertheless pragmatic in recognising the beneficial influence of technology on medical outcomes. He illustrated this conflicting medical priorities of cure and of care with his own experience of undergoing hospital tests during which he ‘felt less like a human in trouble and more like a scientific problem to be solved as quickly as possible’. He however felt that any sense of depersonalisation and dehumanisation he experienced was overshadowed by the ‘absolute confidence I felt in the skill and intelligence of the people who had hold of me’. Just as he regretted that ‘medicine is no longer the laying on of hands‘, and ‘more like the reading of signals from machines’, he nevertheless acknowledged that this transformation is ‘here to stay’ because ‘the new medicine…is a vastly more complicated profession’. He indeed argued that the increasing expectation of patients for ‘quick and effective‘ treatments far outweighs their need for comfort, most of them understanding that it is largely due to the new technology that they can ‘go home speedily, in good health, cured of their diseases’. He however warned that technology must not lead to the total transformation of the doctor’s role from caring for the sick to ‘looking after machines‘ because this would be a price that would be too high for the profession to pay (pages 52-57 and 211-212).
A most discerning theme of the book is the author’s insightful perspective of the role of nurses and their relationship with doctors. In exploring this subject, he expressed unstinting respect and admiration for nurses particularly when he extolled the ‘comfort and reassurance‘ they provide patients. He asserted that nurses are the ‘unique human beings’ who are ‘holding the place together‘ and who are ensuring that ‘the whole institution doesn’t fly to pieces‘, adding that it is ‘by the nurses and by nobody else‘ that the institution is ‘enabled to function as an organism’. Further extolling the exceptional role nurses play in patient care, he argued that ‘it takes a confident, competent, and cheerful nurse, there all day long and in and out of the room on one chore or another through the night, to bolster one’s confidence that the situation is indeed manageable and not about to go out of hand’. On the historically testy relationship of doctors and nurses, the author chided the whole cadre of medical practice for their misguided view of nurses, going as far as to state unequivocally that ‘I am all for nurses…I am on their side‘ (pages 62-65).
A recurrent theme in the book is the central place of emotions in patient care and the need for doctors to appreciate this. The author was particularly worried about the progressive decline of empathy in the medical profession, a situation he partly attributed to the fact that most contemporary physicians have no experience of ‘the killing or near-killing illnesses‘ of the past such as tuberculosis; this, he contended, is in contrast with previous generations of doctors who were often victims of such diseases and therefore ‘had a pretty good idea of what it was like for a patient’. The author emphasised this point further when he said that ‘to have things go catastrophically wrong, and to be personally mortal…makes for a better practice‘. He also discussed the emotion of hope which he depicted as ‘a kind of medicine‘ by which patients ‘do better, live longer, and recover more often’. Hope, he also asserted, is a significant factor in the care of people with cancer who he said ‘know there is no real hope‘ but nevertheless ‘need hope more than anything’. In this interesting perspective on hope, the author conceived of chemotherapy as less a cure and more an offer of the hope of ‘a brief extension of living’, and this gives the elderly time to ‘set affairs in order’, and the young the hope that new therapies will emerge (pages 205, 215 and 187).
A large part of the book is autobiographical in which the author humorously documented his experience of growing up seeing his father practice medicine in the period leading up to the Great Depression – ‘watching him and listening to him’, and ‘taking a great interest in his doctor’s bag’. He noted that the medical literature of the time made ‘horrifying reading‘ because it promoted such ineffectual and potentially dangerous treatments as ‘bleeding, cupping, violent purging, the raising of blisters by vesicant ointments, the immersion of the body in either ice water or intolerably hot water‘ and ‘endless lists of botanical extracts‘. He chronicled his own interestingly diverse medical career from medical school to medical administration, and he dispensed invaluable advice and tips along the way. It was however his commentary on the speculative and error-prone nature of medical research that was most incisive. Arguing that many research hypotheses are wrong, and that error is ‘the mode’ when making research predictions, he pointed out that ‘more often than not, our finest predictions are chancy, based on what we imagine to be probability rather than certainty‘. He particularly underlined the benefit of error in research when he said ‘in order to get anything right, we are obliged first to get a great many things wrong’. He however maintained that the correct strategy is in ‘bouncing back to try again’ because the ‘really important’ predictions ‘turn out, from time to time, to be correct‘ (pages 5-12, 19 and 79-80).
Part medical history, part autobiography, part philosophical musings, this book is a refreshing take on what medicine is, and what it used to be. The comparative perspective is particularly significant today because it provides a clear account of the tensions that have always threatened healthcare, within its practitioners on the inside, and by technology from the outside. Practical and realistic, the author accepts the inevitable downsides of the technological advances that have typified medical progress, but he also advocated maintaining the practices of old which symbolise the medical profession at its best. The book also highlights the need for members of the health team to appreciate each other’s invaluable contributions and thereby banish unhealthy professional rivalries. The author’s prose, very warm and conversational, is equalled only by the wisdom and foresight it contained, and his views, unconventional but perceptive, are as relevant today as when the book was written.
This book is a refreshing perspective on the state of medicine and its place in the wider scheme of society. Expressing originally perceptive views, and drawing from a wide range of experience – medical, academic, and administrative – the author has drawn lessons of inestimable value for physicians which have major implications for their individual careers and their relationships with other healthcare practitioners. The reflective contents of the book are educational and enlightening, and I recommend it to all doctors.
Publisher, Place, Year: Penguin Books, New York, 1983
Number of chapters: 22
Number of pages: 256
Star rating: 5