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Finding the ‘essence of medicine’ for today’s pediatrician
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It will be better that I should ask you a question: Is the physician, taken in that strict sense of which you are speaking, a healer of the sick or a maker of money? And remember that I am now speaking of the true physician. A healer of the sick, he replied ... Then, I continued, no physician, in so far as he is a physician, considers his own good in what he prescribes, but the good of his patient; for the true physician is also a ruler having the human body as a subject ... — Plato, “Republic”
Always seek your own interests, make of a high and sacred calling a sordid business, regard your fellow creatures as so many tools of trade, and, if your heart’s desire is for riches, they may be yours; but you will have bartered away the birthright of a noble heritage, traduced the physician’s well-deserved title of the Friend of Man, and falsified the best traditions of an ancient and honorable Guild. On the other hand, I have tried to indicate some of the ideals which you may reasonably cherish ... consistently followed it will at any rate give your youth an exhilarating zeal and cheerfulness which will enable you to surmount all obstacles—to your maturity a serene judgment of men and things, and that broad charity without which all else is naught—to your old age that greatest of blessings, peace of mind, a realization, maybe, of the prayer of Socrates for the beauty in the inward soul and for unity of the outer and the inner man. — Sir William Osler, MD, Teacher and Student in “Aequanimitas,” 1905
What’s wrong with the world 2day? Things just got 2 get better Dear Mr. Man, we don’t understand Maybe we should write a letter. — Prince, “Dear Mr. Man,” 2004
What is the essence of medical practice, and how does it relate to a better model of care and a sustainable future for pediatric primary care? This question, of course, assumes that a better model of care includes primary care, and while it doesn’t claim a permanent place for general pediatricians in providing that care, I truly hope one exists.
Since the 1970s, primary care has been defined in variable fashion as first encounter, longitudinal and integrational care, while many add coordinated, comprehensive, accountable and community-oriented. I would include affable. Its importance is touted in all the more important white papers, flip-chart and PowerPoint presentations around town. You might have missed the kudos if you haven’t been able to leave your office before 7 p.m. this past year and don’t usually have time for middle-of-the-day meetings.
Don’t feel too bad that you missed them; the authors are often dismissive of those who actually perform primary care. A similar atmosphere also infects medical schools where the pinnacle of success appears to be the welfare and grooming of the best and brightest to pursue the career paths of dermatology, plastic surgery and orthopedic surgery.
Our search for the essence of medicine, of health care, takes us back thousands of generations. In the Republic, Plato has Socrates ask Thrasymachus the above question and, in doing so, defines a physician as a healer of the sick whose interest is not his own but that of the patient. Osler’s modern prescription sets the tone for the 20th century physician and is no less powerful in the 21st century — it promises, if adhered to, the zeal and cheerfulness of youth, the judgment of maturity and the peace of mind of a content old age. Even better, it successfully navigates the dichotomy of unity and freedom both individually and as a community.
Special above others
Since Hippocratic times medicine as health care has been defined as special, as good, as moral, as ethical; and most importantly, as the time line supports, ultimately sustainable; unless, of course, we screw it up and need to write Prince’s letter to Mr. Man.
Health care is community-based; it always has been and needs to be going forward. Physicians since ancient times serve their community, and it is that community service that is the essence of medical care, most obvious in primary care, but no less critical in hospital care and now within ACOs. To separate primary care physicians from these larger structures subtracts from the community required to validate the physician role in society; this separation places our social contract as physicians at risk.
Health care is centered on the physician-patient encounter. The office visit is what enriches our patients and truly ourselves. The encounter is in itself therapeutic. Intrusions into that space, both immediate and distant are unwelcome violations of our commitment to heal and of our patient’s trust. Health care is what we provide, not what we are. Language is important: for far too long, in a maddening piece of branding, my local hospital was called Fletcher Allen Health Care.
Health care is relational — it is not a commodity. Physicians provide community service. We exist to establish a compassionate relationship with our patients and their families. For most of the existence of a profession of medicine, physicians provided little in what we would today call effective care. True physicians were, however, able to address the universal need for care and comfort and always put the needs of the patients first.
Care
Care is the soul of medicine. Practicing primary care general pediatrics allows me to strive for beauty in the inward soul and attempt to make the inward and the outward be one. When we consider the future of primary care and better models to provide health care in this country, let us not forget our past and the essence of the true physician.
My model of pediatric primary care is of the community and by the community — pediatricians providing community service that is affable, accessible, accountable comprehensive, coordinated, integrative and longitudinal.
What is wrong with the world today? Maybe we should do more than write a letter.
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- William T. Gerson, MD, is clinical professor of pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.