Richard Moskowitz, MD

For years I have wanted to write something with this title, with no clear idea of what it would be about, or or even what I meant by it, until recently the phrase came back to me as an apt metaphor for what I do and for some broader issues pertaining to the medical profession generally.

Often used as a title, the common noun "doctor" comes from the Latin verb docere, to teach, and is applicable to an advanced level of academic attainment in any field, such as Doctor of Philosophy, Doctor of Laws, "Doctor of the Church," and so forth.  A Doctor of Medicine is thus first of all essentially a teacher or educator, one qualified through training and experience to inform, advise, and instruct about matters of health and illness, both to individuals and the general public.

Although educating about health is one of the most important things that practicing physicians do, it is by no means the only thing, nor is it even the most common or important meaning of the word "Doctor" today, when teaching and learning are regularly upstaged by the urgent requests of sick people to be "fixed" or "done to" in some way.

Indeed, the familiar conception of the medical doctor in contemporary life is precisely the opposite, as a "doer" or performer of specialized diagnostic and therapeutic procedures. This is our sense of the word "doctor" when it is used as a verb, meaning roughly to "tinker" or "fool around with," to make careful adjustments and readjustments until we get the thing more or less the way we want it, contingent to a great extent on our skill and experience, on the art and craft of the profession.

In this vein, we might speak of doctoring a salad or an automobile engine, always with the implication of risk-taking, and the possibility of ruining it beyond repair, of making some mistake that cannot be undone, in exchange for the estimable benefit to be enjoyed if it is done perfectly, or at least well enough.  Doctoring in this activist sense implies the existence of some standard, goal, or desired endpoint, and here too we can distinguish two subtypes which coexist in practice but differ fundamentally and often compete with each other.

One is older and more primitive, comparable to doctoring the salad, which is judged according to its taste, freshness, and nutritional value.  In this most basic kind of doctoring, the goal of doctors and patients alike is simply to improve how we feel or function according to our own individual standards.  This huge, all-purpose category begins with subjective feelings, such as happiness or well-being, energy or vitality, equanimity, freedom from pain and suffering, and the like.  But it also includes measured observations by family members, friends, employers, and teachers, as well as the patients themselves, as to their performance in work, career, school, marriage, relationships, and family life.  Collectively these variables encompass the rather vague and imprecise but indispensable human criteria that doctors and patients have always used to evaluate their work together since the earliest times.

Corresponding more closely to our second example of the car mechanic, the other aspect of doctoring is distinctly modern in being more objectively and even quantitatively defined, and in regarding the human organism as a machine with separate and more or less exchangeable parts.  In mechanical doctoring, the narrower goal of identifying and removing obstacles to health is achieved primarily by developing performance criteria as precise and unambiguous as possible, in order to be equally applicable to and measurable in other patients with similar conditions.  Morphological and statistical deviations such as abnormal cells, pathogenic bacteria, X-ray shadows, elevated blood pressure, serum cholesterol, etc., can then be substituted for all the subjective and idiosyncratic elements of illness, which tend to be too crude to define or measure and too unpredictable to control.

Modern doctoring employs both of these styles simultaneously and cannot be carried out effectively with either of them alone.  But in practice they are often rivals, each representing a distinct conceptual language that is supple and powerful within its own sphere, but utilizing methods and purposes that cannot always be reconciled, and appealing to standards that are often untranslatable.  I shall call the first the ordinary or "human" language of lived experience, and the second the technical language of abnormalities.

While demonstrably more precise and accurate for certain specialized purposes, the newer technical language of medicine nevertheless ultimately derives its own meanings and values from the older human or ethical standard.  The only conceivable rationale for giving drugs to lower the blood pressure and prevent strokes and heart attacks is that such a life will be fuller, richer, and happier than otherwise.  The same is true of surgery, which would succeed far less often without the language of abnormalities, and its extraordinary ability to identify and regulate critical life functions on a moment-to-moment basis, a truly magnificent achievement.

Yet even for surgeons, the ultimate test of diagnosis and treatment is the same one that doctors and patients have always used, namely, do they help?  Do they relieve suffering and disability?  Do they promote the health of the patient as a whole?  Do they minimize our long-term dependency on the medical system? Such questions cannot be asked or answered meaningfully from any viewpoint except that of the patients who are subjected to them.

In short, the technical language of the physician is a derivative language and should only be used to facilitate or clarify the awareness of the patient, not substitute for it.  The older phenomenological language arises directly from our personal awareness of ourselves and our bodies as sensed, imagined, thought, and felt.  With all its limitations, the subjective awareness of how we feel and function is still the bottom line for what doctoring is ultimately about.

Especially in a profession dominated by science and technology, it provides our best assurance that health and illness, improvement and worsening, and the success or failure of our work as physicians will be judged according to the patient's own standards, rather than others imposed arbitrarily or coercively by and for the profession itself.  Our failure to keep these priorities straight is a lot of what I hear from patients about what they think is wrong with medical system today, and it is difficult not to agree with them.

I'll say it the other way: the excesses and deficiencies of the present medical system are intelligible and predictable to the extent to which we have reversed these priorities.  By subordinating the ordinary language of the patient to the technical jargon of the physician, we have replaced our sacred and noble calling of healing the sick with the purely technical imperative of acquiring the knowledge and devising the means to manipulate and control biological processes artificially and more or less at will.

This brings me to the adjective "plain," the first word of my title, which I can now understand why I chose even before I knew what to write about.  To me, "plain doctoring" means simply reaffirming the ordinary language and thought of our patients as the truest standard for evaluating our sophisticated diagnostic and therapeutic interventions, the basic human wisdom that alone can guide or restrain us in their use.

The word "plain" also means "generic" rather than specialized, and refers to those aspects of health and illness that are universal and fall within the province of every physician and every patient.   Such would naturally include the experience of falling ill, worsening, and recovering, with their attendant lessons of pain, suffering, disability, and the proximity of death.   Nor could they overlook the corresponding gifts of giving birth and being born, of health and vitality, of tranquility and joy,  and healing and being healed.  None of them can be understood outside the context of actual human life, and all of them are part of the life experience of every human being.

Finally, plain doctoring is blissfully neutral with respect to the Cartesian riddles and rivalries of mind and body, for the simple reason that the seamless biological integrity of each living creature must take precedence over the mental or physical subcategories we learn to use of in our study and practice.  When we see our patients, we encounter physical, mental, and emotional symptoms, all in the soup together: neither making the diagnosis nor instituting the treatment need impose on us any prior metaphysical commitment to any particular subset of them as having "caused" the others.  Our job is simply to taste the soup.

In addition to these general remarks that most of my readers can identify and even perhaps agree with, I retain my own personal version of plain doctoring that I try to live by in my own practice.   Though far from perfect, and everywhere subject to my own full share of limitations and failings, it works well enough for me and my patients alike that I can write these lines without shame and practice medicine credibly in their sight.  I hope that simply talking about it publicly in this fashion will stimulate and encourage others to come forward and articulate what plain doctoring means for them.

My basic text is from Paracelsus, the great Renaissance physician, who prophetically formulated a great deal of what modern medicine seems to have contrived to ignore:

 

The art of healing comes from Nature, not the physician . . .

Every illness has its own remedy within itself . . .

A man could not be born alive and healthy were there not already a Physician hidden in him . . .(1)

 

I interpret them roughly as follows:

 

1. Healing implies wholeness.

Etymologically, the English verb "to heal" comes from the same root as "whole," meaning essentially to make whole [again], and refers to a basic attribute of all living systems, which is evident both in wound healing and in spontaneous recovery from illness, and is implied even in effective medical and surgical treatment, our standard Operating-Room alibi "poor protoplasm" signifying the relative deficiency of it.   Like the metastatic cancer patient who pulls off a regression against every probability or expectation, healing represents a concerted response of the entire organism, cannot be achieved or ascribed to any part in isolation, and implies a deeper level of integration than could be defined or approximated by any mere assemblage.

2. All healing is self-healing.

As a fundamental property of all living systems, healing proceeds continuously throughout life, and tends to complete itself spontaneously, with or without external assistance.   This means that all healing is ultimately self-healing, and the role of physicians and other professional or designated healers must be essentially to assist and enhance the natural healing process that is already under way.  However useful and necessary it may be, merely correcting abnormalities will also have to be judged in relation to that fundamental standard.  Finally, a self-healing orientation transforms the doctor-patient relationship itself, from a hierarchy of knowledge and command into a partnership of consensus and trust.

 

3. Healing pertains solely to individuals.

Always possible but also inherently problematic and even risky, healing applies only to individuals, to flesh-and-blood creatures in unique, here-and-now situations, rather than to abstract "diseases," abnormalities, principles, or categories.  In other words, whatever else it may be, it is inescapably an art, and should never and can never be reduced to a mere technique or procedure, however scientific its foundation.

To these three aphorisms I would add a fourth of my own, arising directly out of what I hear patients complaining about, which may need to be affirmed as a basic moral, legal, and political right of what it means to be a patient:

 

Health, illness, birth, and death are inalienable life experiences belonging wholly to the people undergoing them, which nobody else has the right to manipulate or control without their explicit request, or that of somebody duly authorized by them to act on their behalf.

 

My concluding text is from Lao-Tse, and supplies an appropriate bottom-line criterion:

 

A leader is best when people barely know he exists,

Not so good when they obey and acclaim him,

Worst when they despise him.

Of a good leader, when his work is done and his aim fulfilled,

The people will say, "We did this ourselves."(2)

 

 

 

 

 NOTES.

 

1.   Selected Writings of Paracelsus, ed. and N. Guterman, Pantheon, New York, 1958, pp. 50, 76.

 

2.   Lao Tzu, The Way of Life, trans. W. Bynner, Perigee, New York, p. 46.

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