Sunday, April 29, 2012

The First Aphorism

"Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgement difficult.  The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals, cooperate."

The above is an interpretation of Hippocrates' first aphorism as interpreted and printed in "The Uncertain Art: Thoughts on a Life in Medicine," by Sherwin B. Nuland, MD.  I can't say yet that the book is any good - still only about three chapters into it.  But the aphorism itself is...  well, a single adjective doesn't really describe it well enough.  It is insightful, thorough, and something that each PA student, NP student, and medical student (osteopathic or allopathic) should be introduced to.  It is daunting to undertake the charges given; it is in some ways difficult to wrap ones brain around them all; it manages to convey in just a short piece of text the history of the medical profession, the responsibility that we all bear in our clinics, offices, and hospital wards, and even to provide ethical guidance to help us operate in gray areas. 

With all of these things in mind, I want to discuss it in a piece-by-piece fashion.  I can't tackle it all at once, obviously, so we'll begin with the first phrase - "Life is short, and the Art is long."

It is attributed that Hippocrates was discussing medicine when he penned this in roughly 400 B.C.  "The Art," thus refers to the art of medicine, I believe.  This appears to be widely accepted.  Life is short, and the Art is long - to me this says something on several levels. 

The first thing I take away from this is of course that my life will be too short to fully understand every facet of the art of medicine.  I will never know all that there is to know...  Nor will any of us.  Every month of every year (perhaps even every day) scientists and doctors (and PAs and NPs) discover new things about medicine that are, in some cases, revolutionary.  We used to believe that if someone was bleeding out on the ground then we should pump them full of fluid to keep their blood pressure up.  Just recently, with protracted wars in two theaters, we've discovered through methodical analysis of military medical records that normal saline or lactated ringers pumped into the body of a bleeding patient actually decreases their chance of survival.  Yet the principle has been our M.O. for greater than 5 decades.  I will never be able to sew in a coronary artery graft, nor will my doctor.  The cardiac surgeon who does these will never be as adept at managing an ankle sprain as I or the orthopedic surgeon downstairs are.  Not one of us will ever get it, 100%.  This has many ramifications - communication between us being the most obvious.  But willingness to cooperate and share responsibility for people - as I've talked about in the past - is another thing that comes to mind.  In order for our patients to get the best care possible with front line approaches, it requires a multiple-specialty team. 

On another level, this phrase shows me that when ailment strikes, the lives of our patients become quite short if we don't do the right things at the right moments.  Life is fragile in many ways when illness or injury comes into the picture.  The meaning of the second snippet could be that medicine can take too long to have its effect and save a life, or it can mean that in these instances when disease has struck there is much that needs to be understood in order to fix an ailing patient.  In an older patient with acute onset of delirium tremens in the setting of pancreatitis who sustains rib fractures and bleeding into the chest - where should I begin?  What are the physiologic mechanisms by which this patient has become sick?  How do I correct them?  Why does the calcium level in this patient's blood drop precipitously?  What is the mechanism by which the albumin is low?  What happens to this body when albumin is low and how do I correct it?  How do we manage the bed sores that might develop?  What is the physiology of respiration and how does it affect all of the other stuff I've already mentioned?  Would someone who wasn't well trained in the Art be ready to manage this patient when time matters and even an hour's delay could be the difference between life and death for this person?  Obviously the answer I'm getting at is, "No."  Life is short, and the Art is long. 

When taken at face value we can admit that life is indeed short, medicine indeed takes a lot of time to learn.  It takes even longer to become proficient with it.  This is perhaps the simplest meaning to be taken from the first phrase, but all of the other stuff that I mentioned is hidden more deeply underneath the surface.  And all of it, in the end, comes into play when we're taking care of our patients on a day-to-day basis.