Diagnosis is more than just scanning a deviation from normal. "The eye is for accuracy, the ear is for truth," long my watchword, suggests how easier it is to look at computed axial tomography scans than to listen to the patients they stand for. I want to talk directly with patients. Every patient is different; every physician "takes" the history in a different way: the time of day, the blinking of the eyes, the pause between question and answer; those details influence how – and what – doctors hear. Just as listening for the whoosh of aortic insufficiency might vary with the ears of a cardiologist, so what the patient tells a physician can be as ephemeral as a butterfly.
I am an old man, trained in a distant era, and we elderly always think things were better when we were young. I might have been better then, but medical practice is far more accomplished now. Yet, our medical practice was more humane, physicians were more attentive to patients, and there was far less talk of money. Wrongly, my generation never talked with our patients about sex, politics, or religion, but we did look at the big picture and were satisfied with less than specific answers, and physicians mostly had a good time, maybe – my wife Marian reminds me – because we had never heard of "informed consent."
Science has replaced religion; philosopher Paul Feyerabend has pointed out that "people are free not to believe in God, but they are no longer free not to believe in Science." Evidence-based medicine has provided 21st century physicians our new faith in what has been proven by "double-blind" randomized controlled studies. Evidence brings blessed assurance of numerical truth, despite subsequent wrangles about appropriate statistical exegesis.
Some of us old folks wonder how reliable is the evidence-based medicine that now dominates medical practice; critiques of clinical reports come from statisticians in the search for mathematical certainty. Many clinical decisions have fuzzier borders than decimal points suggest. Deaf to their patient’s words, clinicians treat the "average" patient by the rules.
Every action brings a response, and so during the past few years, renewed attention to the humanities, to novels, and narratives of illness have comforted clinicians. Narrative Medicine, as some call it, helps physicians to understand the human dilemmas that evidence-based decisions seem to avoid.
Some years ago I saw a young Hispanic woman whose chronic nonspecific abdominal pain had defied her doctors’ depredations until the detection of H. pylori. Through an interpreter, I learned that her husband beat her, she had had four failed pregnancies, her only daughter with spina bifida was confined to a wheelchair, and she was on welfare and could not work. She did have those antibodies to H. pylori; they were new and in those days an exciting finding. However, as I listened to her story, I wondered how her doctors hoped to blame her dyspepsia on those tiny bacteria at home in her stomach.
Gallstones are wrongly taken to be responsible for much abdominal unrest. One out of 100 people with asymptomatic gallstones develop biliary colic each year. That first attack is significant; the 50% chance of a second attack makes it prudent to get rid of the offending gallbladder. However, let incidental "silent" gallstones show up on whatever image, and in 2012 the belly button will quickly be violated.
Suppose a college student with ulcerative colitis returns to tell his doctor how much better he feels after some pills were prescribed. His gastroenterologist might well sniff, "Great! Let’s have a look!" Only after peering into the rectum once again will the doctor declare, "Oh yes, you are feeling better!" Happily, the doctor gets paid for that quick look far more than for listening to the boy’s jubilation at feeling better.
I became a stomach doctor at age 24 and passed the stiff endoscopes we labeled "flexible" with enthusiasm. I gave up "doing procedures" at 40, when development of fiberoptic instruments warned that I might be spending more time with patients inaudibly at their backside than face-to-face listening to their stories.
I do not belittle the technologic advances that have much strengthened clinical practice. However, giving up endoscopy gave me the time to listen to the words as well as to the intestinal gurgles of my patients, many told me stories few others would hear, and I could put their images into context. Many of them complained of what I took to be "existential pain" that had no defining source aside from the sorrows of living. Abdominal pain that never wakes the patient up and that is just there all the time, unmoved by food or motion, is likely to have no discernable origin in the belly. Each new diagnostic tool uncovers some previously unseen abnormality that tempts the physician to remove or treat it, often unavailingly. The list is long, beginning with "antral mucosal prolapsed" of my youth and continuing all the way to sphincter of Oddi "spasm!"
