Y]ou tell me you are thinking, my dear Stephen, of medicine as a career, but you wonder whether you have the ability or the temperament for it. You say that you have wanted to be a doctor ever since your family practitioner visited you at home as a child when you had severe tonsillitis. He seemed a hero to you then, and you would like to emulate him.
I do not want to discourage you, of course, but the kind of doctor who visits patients in their homes was not common even then (you were lucky) and is even rarer today. If you are to avoid disappointment or bitterness, you should have a clear picture of what modern medicine really entails before committing yourself to it.
Medicine is a broad church, and the kind of person it requires is therefore very varied. Provided you have the requisite determination and intelligence, which I do not doubt, you need not worry too much about your temperament: There is a branch of medicine to suit every one.
That said, the road is not easy. No profession makes so many psychological demands on its practitioners as medicine. You will have to tolerate the folly of patients while striving to promote their well-being. You will discover that the varieties of human self-destruction are infinite, ranging from persistence in the most obviously harmful habits despite stern warnings to the most absurd beliefs about diet—such absurdity being by no means confined to the ignorant and uneducated. Superstition springs eternal, and you must remember that an age of information is also an age of misinformation. Many of your patients will be cranks who believe that fish oil or guava juice is the elixir of life, or that wearing a crystal round their necks or living on a healing chakra of the earth is the secret of health. They will have all kinds of unfounded beliefs, some harmless and some harmful, and you will not be able to dissuade them.
Other patients will be outright unpleasant, unreasonably demanding, and even threatening. They may try to blackmail you: For example, patients have told me that they would kill someone or themselves if I did not prescribe them what they wanted. I refused, advising them to refrain from killing anyone, including themselves, but I could never be quite sure that they wouldn’t carry out the threat.
Whatever your inner state of turmoil when confronted by the immense showcase of human folly or unpleasantness, you must retain your outer equanimity, which does not come naturally and at first will take a mental toll on you. But habit will become character, and eventually you will learn to accept people as they are—even if they don’t deserve it.
You will also have to learn to tolerate intellectual or scientific uncertainty and ambiguity. While there are undoubted scientific truths—such as the circulation of the blood—that no one seriously believes will ever be overthrown, much of your knowledge will inevitably be provisional, valuable and viable only until better evidence comes along. This is particularly true where prescribing medicines and performing procedures are concerned. Subsequent research often shows that cherished treatments are of little or no benefit, and are sometimes harmful. The history of medicine is replete with instances of beliefs firmly held by doctors that turned out, on investigation, to have been false and that subsequent generations of doctors have found almost ridiculous.
One obvious example is the persistence of bloodletting down the ages, advocated by doctors with fervor for hundreds of years until a French physician and pathologist, Pierre-Charles-Alexandre Louis, showed early in the nineteenth century that it was useless in cases of pneumonia, for which it was then the orthodox treatment. You must therefore hold your scientific beliefs lightly but not frivolously, and try not to invest them with too much emotion or make them the entire basis of your self-respect. You must understand that to have been wrong is not necessarily a disgrace, while to persist in an error to the detriment of your patients, simply because it is too painful to change your mind and practice, is indeed sinful.
The philosopher Bertrand Russell said that the rational man is he who holds his beliefs about the world with a strength precisely proportional to the strength of the evidence in their favor. This would be a counsel of perfection even if it were true, which it is not. I doubt whether there has ever been a rational man according to Russell’s definition, for we cannot know with any degree of precision the strength of the evidence in favor of most of our beliefs, and therefore we cannot order them as Russell’s dictum would require us to do.
As doctors, we need the humility to realize that we were wrong when research corrects false truisms. But we also need the corresponding hope that we might be right. Skepticism alone paralyzes. An inspiring example of the self-belief that may lead to important discovery is that of Dr. Barry Marshall, the Australian co-discoverer of the bacterial cause of most peptic ulceration.
It is difficult to overestimate the amount of human misery that this relatively simple discovery has prevented. Until then, untold thousands of people with peptic ulceration suffered for many years, often for decades, and were subjected in the search for alleviation of their symptoms to serious operations with adverse after-effects and of variable efficacy. They took large quantities of medicines that at best reduced symptoms for a time. They had to follow distasteful diets, making one of the simplest of pleasures in life, eating, at best a dilemma, at worst a torture.
Dr. Marshall’s theory that the disease was caused by a germ found in the stomach, Helicobacter pylori, seemed to many (including to me) far-fetched. The germ had been observed for many years to exist in the stomach, but since it was obvious to all that peptic ulcer could not possibly be an infectious disease, the germ was regarded as a curiosity rather than as a factor. We knew that peptic ulceration was more common in smokers and in those of a type A personality, that is to say, the hard-driving, ambitious type of person, and therefore that the disease was not infectious. Dr. Marshall, however, approached the question with an open but not uninformed mind—an open and an empty mind not being at all the same thing. Within a very few years, his experiments convinced the world that he was right, and he was awarded the Nobel Prize.
Of course, it is not given to many doctors to make a discovery such as Dr. Marshall’s, but his disciplined skepticism combined with the courage to venture a new hypothesis is a frame of mind that you would do well to cultivate. This is all the more the case in an age of so-called information, when you will be bombarded with propaganda masquerading as scientific truth. To resist it will be very difficult to do because you will be so busy that you will have very little time for critical thought.
Let me give you a concrete example of the dangers of not thinking critically. In 1980, a letter was published in the New England Journal of Medicine pointing out that patients in hospital who were prescribed strong opiates for post-operative, heart attack, or cancer pain never became addicted to the drug they were given. At the time, doctors withheld opiates from patients who would have benefitted from them because they, the doctors, were afraid that they might addict their patients to them.
Later, when synthetic opioids became available that were just as dangerous and addictive as the natural opiates, the letter in the NEJM was cited both by the drug companies that manufactured them and medical evangelists of pain relief as evidence that they might be prescribed to patients with any kind of pain whatever. Many doctors threw caution to the wind and began to prescribe these opioids with abandon to patients with various kinds of chronic pain, usually of ill-defined or uncertain pathology that was much more related to what might be called their situation in life than to any definable illness. They continued to prescribe these drugs despite abundant evidence that they were not effective in relieving the type of pain for which they were prescribed.
This, then, was the start of an epidemic of addiction to opioids that is now causing tens of thousands of deaths yearly by overdose in the United States. The epidemic would have been avoidable if doctors as a whole had adopted a more critical and thoughtful approach from the first to the supposed arguments for prescribing these drugs. It should have been obvious to any doctor of minimal experience that the two types of patient, those with acute or cancer pain and those with chronic pain of vague and uncertain origin, are very different. Proper treatment of one group of patients cannot automatically be applied to another, quite different group.
In extenuation of the doctors who unwittingly started the epidemic—not a few, incidentally—it can be said that they had been targeted by intense commercial propaganda and reassured by supposed leaders in the field of pain relief that their prescriptions were right and proper. This brings to light a contradiction with which you will have to wrestle for the whole of your career: the contradiction between the authority of others and your own personal responsibility.
You cannot dodge your personal responsibility by hiding behind the authority of others or the consensus of the profession. But at the same time, you will be expected to do as other doctors do. Early in your career, you will necessarily be subordinated to the authority of more experienced doctors. With luck (and in most cases), those doctors will instruct you to do the right thing, both technically and morally, but there is always the possibility that they will not. Later in your career, you will find yourself subject to an ever-increasing number of rules and regulations, many of which will appear to you as absurd at best and contrary to the interests of patients at worst. But you will have to obey them as a condition of continuing in practice.
As the technical possibilities of medicine advance, especially in genetic engineering, so will ethical dilemmas increase in number and gravity. But even now storm clouds are brewing; indeed, they have already brewed. I will give you a simple example. Medically assisted suicide is increasingly claimed as a right: A man, according to this line of thought, has the right to choose the hour and manner of his death in order to avoid suffering. From this, our age deduces that a doctor has the duty to administer the lethal means to exercising that right. That doctor may well be you. You went into medicine to save life, and you will end up by (in effect) killing.
There is no reason why assisted suicide should be confined to the dying. Why should those suffering from taedium vitae be denied the soothing final injection? There is nowadays a tendency for rights to spread, like ink through blotting paper. Abortion was originally intended to be performed in limited circumstances only, but now has become an inalienable right in any circumstances whatever—into which, indeed, it is impermissible to inquire. A right, after all, is a right; in our times, any limitation is treated as an illicit abrogation of that right.
Moreover, though we pay lip service as a society to diversity and tolerance, we increasingly demand uniformity. A recent article in the New England Journal of Medicine argued that doctors should not be permitted to opt out of performing procedures that they considered unethical on the grounds of conscientious objection. Once the profession, guided by ethicists, had decided as a whole that something was ethically permissible, no doctor should be allowed to go against the consensus. This, of course, would have the corollary that mass murder by doctors would in theory be permissible, or even obligatory. Never mind: It can’t happen here. But what was once unthinkable can become thinkable very quickly.
At what point you rebel, and how you rebel, against a prevailing ethical consensus will always be a matter of judgment, since it is a fact of human existence that no one can live only and exclusively according to his own lights but must always compromise. In all of this, you will have the responsibility to treat your patients according to the best methods and evidence possible.
Here, too, you will have to exercise your judgment. For example, patients will often ask your advice, despite having searched everything on the Internet in advance. But information on the Internet, apart from sometimes being mistaken, is raw information, and you will be looked to for wisdom and experience as much as for information. Moreover, to many questions there is no indubitably correct answer.
The open-ended character of medical judgment has increased a great deal because the very nature of medicine has changed. It used to be that patients went to doctors when they were ill and hoped for a cure, either surgical or pharmacological. (This is probably the picture of medicine as a profession that you have in your mind.) The transaction in those days was, at least conceptually, straightforward: diagnosis, course of treatment, results. Now doctors spend much of their time treating not illnesses, but risk factors for illnesses. For example, the higher a person’s blood pressure, the greater his risk of heart attack or stroke, but high blood pressure is (except in its most extreme form) symptomless. You don’t know you have it until you experience one of its complications.
Drugs are used to reduce blood pressure, but they have to be taken regularly and often for the rest of a person’s life. Their purpose is to reduce the statistical risk of heart attack or stroke. They can have side effects. At least half of people prescribed antihypertensive drugs have stopped taking them by the end of the year. Most people who take them will not benefit from them, though when someone does benefit—by not having the heart attack or stroke he would otherwise have had—it is a very great benefit indeed.
The question of whether it is worthwhile for someone to take antihypertensives cannot be answered with a simple yes or no. It depends on the size of the risk and the values of the person taking them. Some people prefer to take their chances than take the pills; others take any number of pills all their lives for a minimal reduction of risk. Neither type is right or wrong, clever or foolish. As a doctor, you have to learn to accept people as they are.
The object of medicine is to prevent and cure illness, thereby reducing suffering and prolonging life, but it is also to bring comfort where cure is not possible, as often—even nowadays—it is not. A doctor exerts a powerful placebo effect and cannot afford therefore to present himself as a Hamlet, dithering on the horns of an insoluble dilemma because he does not have absolute certainty about what it is best to do. The noble lie is therefore sometimes permissible, not in the strict sense of passing off falsehoods as truth, but in accommodating human vulnerability. This can mean projecting a false confidence in what you know as the correct but by no means inevitably successful course of treatment. In some circumstances, a patient diagnosed with a dire affliction may ask, “Will I live?” You do not have a duty to tell him the strict truth (“In all likelihood, you’re doomed”). In some situations, you’ll have to use your judgment, saying, “We’ll do the best we can.”
Truth is obviously very important in medicine as in other endeavors, yet too strong an insistence on telling the truth to patients may easily degenerate into sadism. Our mortality is a heavy burden. Sometimes speaking frankly about dying lightens the load; at other times, it brings a soul-crushing gloom to already dark moments. No doubt medical ethicists will try to present you with a checklist of absolute principles to follow, such as always telling the truth, the whole truth, and nothing but the truth. This is wrong. Judgment, as the father of medicine, Hippocrates, said two and a half millennia ago, is always fallible, but it is always necessary. You’ll make mistakes, but you must learn from them rather than be destroyed by them.
You must keep in mind that you can do harm as well as good. (Again, it was Hippocrates who said, “First do no harm.”) The good that you do will be manifest, but the harm often hidden. In this respect, medicine is like economics. Let us suppose that you are able to measure a chemical in the blood for a certain kind of cancer, which you then treat. You congratulate yourself on having saved a life. But let us suppose that, because your test is not specific enough and often proves positive in cases of people who do not have the cancer, or whose cancer will not kill them, you diagnose cancer in nine people who do not have it or in whom it is not dangerous. You will have caused unnecessary anxiety to many people, and possibly subjected them to worthless and sometimes dangerous operations, in order to save one life (as well, of course, as having inflated the expense of medicine). This can be a very serious problem in so-called screening procedures; the harm that they do can sometimes exceed the good that they do. Therefore, bear in mind that something should not automatically be done just because it can be done. You must never cease to think critically on behalf of your patients.
In reading medical journals, you will have to develop an instinct for the kind of legerdemain that (alas) they often employ. Most doctors are too busy to read them with care and attention; they just skim the summaries and conclusions of the papers that they contain. This is not sufficient.
Let me give you one or two examples of the pitfalls (though there are many others). Often a paper will say in conclusion that there was a statistically significant difference between a and b, where a and b can be treatments or risk factors for disease. But the practice of medicine is more than an intellectual exercise; its ultimate end is always the welfare of patients. A statistically significant difference is merely a difference that is unlikely to have arisen by chance, but that does not in the least tell you whether it is significant in any other, ultimately more important way.
You must always keep in the back of your mind that statistical association is not proof of cause and effect. Having examined the level of consumption of commodity a in population b, and correlated it with the prevalence of disease c, often with the aid of sophisticated statistical calculations that you will not understand, authors may come to the conclusion that in population b, the relative risk of contracting disease c of those who consume commodity a is raised by 20 percent, and then proceed to speculate about how a causes c. When publicity is given to this type of research, panics often ensue, and people change their habits for no good reason.
Moreover, when risk is expressed relatively, you must remember that what matters to your patients is the absolute risk. If someone has a risk of contracting a disease that is one in two million, it does not matter very much if his risk is doubled by eating macadamia nuts, even if it is assumed that the macadamia nuts cause the increased risk. Where risks are given relatively but not absolutely, something fishy is going on, or, to change the metaphor, axes are being ground.
I will give you a recent example. A paper was published in the Lancetwhich correlated the alcohol consumption in many countries with the risk of death from diseases and accidents assumed to be causally related to alcohol. The work it reported was immensely laborious, involving the cooperation of hundreds of doctors and institutions. It came to the conclusion that the only safe level of consumption of alcohol was none at all. This result was given publicity throughout the world.
The risks were expressed entirely in relative terms: There was not a single figure for absolute risk. Thus it might be, for example, that the relative risk of death of a twenty-five-year-old who drinks alcohol in moderation is 50 percent higher than that of one who drinks none at all, but the chances of a twenty-five-year-old dying in most parts of the world are very slender. A similar difference might have been observed between drivers and non-drivers, football players and non–football players, and so forth. One cannot, or perhaps I should say ought not, lead one’s life according to such calculations. In other words, as a doctor you must guard against becoming a Savonarola of health. Life is about more than not being dead, and a fixation on not dying often takes the joy out of life.
This brings me naturally to another problem of medical ethics that you will face. You will no doubt hear a great deal about patient autonomy, the principle that the patient must be allowed to choose treatment that he wants. And of course it is quite right that patients should not, except under certain very restricted circumstances, be subjected to medical treatment that they do not want. Paternalism in that sense is to be avoided.
Nevertheless, a doctor has an ethical duty often (not always) to be paternalistic in a limited but proper sense. Because human circumstances are so varied, he must be flexible without being unprincipled. It is his duty to tailor what he tells patients according to their capacity to understand, absorb, and accept. As I know from experience of being nigh unto death through illness, the last thing a desperately ill patient wants is a large menu of possible investigations and treatments, with a full and frank disclosure of all the possible consequences of each possible course of action. Patients want doctors who assume responsibility for their care, and that means taking the lead and warmly recommending a plan of treatment, which is a kind of paternalism.
The doctor needs to be wise as well as knowledgeable and technically accomplished. We laugh at the Victorian surgeons who used to say “the operation was a success, but the patient died”—as if it were the patient’s fault—but we are not entirely free of that kind of absurdity ourselves.
How then, you ask, do I become wise? No doubt there are some brilliant fools who are ineducable in this respect, but you, my dear Stephen, are not one of them. A doctor should be an educated man in a broader sense than just medicine, albeit that, with so much to learn and keep up with, this is increasingly difficult. You should read at least a little philosophy, some of the history of medicine, and as much literature as possible. If there is one author I would recommend to you, it is Chekhov, himself a doctor. He managed to reconcile tolerance, understanding, humor, compassion, anger at injustice, and maintenance of high personal moral standards without permitting any of them to distort his character.
If there is one prayer that I would have you learn by heart and keep in mind to guard against the common temptation of doctors, it is that which was written in 1953 by an eminent British physician, Sir Robert Hutchison, when he was eighty-two years old, the fruit of long experience and reflection: “From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than endurance of the same, Good Lord, deliver us.”
Theodore Dalrymple is a retired doctor and contributing editor of City Journal. His latest book is Grief and Other Stories.