Medical Tuesday Blog

Letter to an aspiring Doctor

Sep 2

Written by: Del Meyer
09/02/2019 5:54 PM 

by Theodore Dalrymple

You 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.

Theodore Dalrymple is a retired doctor and contributing editor of City Journal
His latest book is 
Grief and Other Stories.

A Review of Local and Regional Medical Journals and Articles

Notes Brevis: Peptic disease is still poorly understood even in the 21st century.
This is still a frequent complaint in the E[1]mergency Rooms.
Severe heart burns at the end of the sternum is frequently complained as “Chest Pain.”
This precipitates the myocardial infarction protocol in the emergency evaluation.
After this expensive evaluation a simple physical exam of the epigastrium reveals exquisite tenderness.
This is essentially diagnostic of peptic ulcer disease or peptic esophagitis which is easily treated.
An ounce of antacids will resolved the complaint in minutes.
If this simple exam had been done prior to the nurse implementing the chest pain protocol, $thousands could have been save.
If patients had understood Dr. Marshall’s understanding and treated themselves at home, even more $thousands could have been saved.
But the learning curve will never curve downward: It will only spiral upward with total health insurance.

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