Medicine without the medicine*

E K Yeoh 楊永強

HK Pract 2003;25:270-272

It is indeed an honour for me to deliver the 14th Dr Sun Yat Sen Oration before this distinguished congregation.

In coming up with a suitable topic for this oration, I was reminded of the work of Sir William Osler, a 19th century physician and one of the most esteemed doctors in the history of medicine. Osler was a strong proponent of family practice. He called family doctors people of noble character who are in the front line of fighting disease, and who emphasise care for the patient, not the disease. It is this aspect of medicine, emphasis on wholeness, balancing the science and the art, that leads me to entitle my oration "Medicine without the medicine".

Modern medicine

Much of medicine and medical practice has changed during the past generation. Modern medicine, powered by advances in medical science and technology, has expanded drastically the realm of medical possibilities. Bodily functions can now be restored through organ transplantation, joint replacement, cochlear implant, etc. Diseases previously untreatable now witness cure on the treatment horizon. Some, such as polio, may even face eradication. Exciting opportunities also await the new sciences of post genomics and proteomics, with impact on prevention, early detection and treatment.

While scientific advances have undoubtedly resulted in remarkable improvement in human life and individual's health, the question is whether modern practice of medicine has become so focused on the science that it has ignored the human aspect of patient-doctor interaction, that is the art of medicine? Has our modern day physician become so narrowly focused on the bio-patho-physiology of disease that important psychosocial factors are ignored, inhibiting the formation of that kind of personal relationship with the patient that enhances effective diagnosis and treatment?

Trafford's article "The empathy gap" provides the answer. It says, "The CT, MRI and PET scans, the lasers, and the laparoscopies, the chemo-cocktails and DNA codes - all the advances that make modern medicine so effective (and expensive) have isolated physicians from the patient as a person. In the process, the ancient therapeutic art of listening is being ignored, much to the dismay of many who recognise the limits of technology".

There is therefore a need for modern medicine to move away from being too reliant on science, technology and medicines, and towards focusing more on the whole person. This means balancing the science and the art of medicine. It also means addressing the notion that "to dish out medicines is easy, but to come to an understanding with patients is hard". I believe striking the balance requires addressing the heart and the soul of medicine, that is doctor-patient relationship.

Doctor-patient relationship

Medicine begins with the doctor-patient relationship. This relationship is founded on a covenant of trust. This covenant obliges the physicians to be competent and to use their competence in the best interests of patients, that is, placing patients as the central focus of care. This patient-centred approach means that the care provided is closely congruent with and responsive to patient's wants, needs and preferences.

Achieving patient-centredness requires the physicians to possess knowledge not only of biomedical and behavioural science but also an understanding of patients as people and the society in which they live. It further requires the physicians to be able to appreciate the questions of "what can be done" and "what should be done" in the provision of care and treatment. The two options are, of course, not synonymous, and should be discussed openly and sensitively with the patients.

The requirements of physicians to possess both understanding and sensitivity of heart are not new. These have long been inscribed in the ancient symbol of our profession: the twin snakes that entwine themselves around the physician's caduceus represent knowledge and wisdom, and the caduceus is a perpetual reminder that we are required to hold them in balance and prevent each from devouring the other.

Hence, balancing knowledge and wisdom is the key to addressing the doctor-patient relationship. In our enthusiasm for biomedical science, or knowledge, we must not lose sight of the need for wisdom in how it is applied. In coming up with treatment options, for instance, it is sometimes preferable to provide care with support and assistance to prevent pain and discomfort rather than aiming for the illusive cure. The key to this is to view the patient as a whole person, and recognise that the patient is an expert too, in the areas of his/her experience of illness, social circumstances, habits and behaviour, attitudes to risk, values and preferences. The patient's knowledge, coupled with that of the physician, are needed together to manage the illness successfully. The doctor-patient relationship described here has therefore moved away from the paternalistic model, towards that of partnership. The new emphasis is on shared information, shared decision making and shared responsibilities.

Holistic medical practice

"Medicine without the medicine" is an optimally balanced, holistic, medical practice in action. Its practitioners exhibit the following characteristics:-

• First, they are competent and compassionate. They also possess humility and acknowledge that they do not know everything. Such humility helps to strike a healthy balance to the professional arrogance to which we are often tempted when assuming our right to treat patients according to our judgement. The advice of the late editor of the New England Journal of Medicine, Franz Inglefinger, is noteworthy. In his lecture entitled "Arrogance", he pointed out that physicians cannot afford to be arrogant simply on the basis of their presumed superior knowledge. At the same time, he also warned that the greater arrogance was that of the ignorant, who feel that they can pontificate despite a lack of knowledge.


• The second characteristics is that they possess good communication skills. Empirical studies have shown that doctors and patients have different views on what makes good and effective communication. These differences influence the quality of interactions between doctors and patients, as well as compliance, patient education and health outcomes. Good doctor-patient communication results in tangible benefits, yielding better patients' satisfaction and improved emotional health, resolution of symptoms, better pain control and physiological measures such as blood pressure and blood sugar concentration. The importance of effective communication skills is further emphasised by an editorial in the British Medical Journal. It say, "compared with most medications, communication skills have undoubted palliative efficacy (often reducing symptoms significantly), a wide therapeutic index (overdose is rare), and the commonest problem in practice is suboptimal dosing".
• The third characteristics is that they exhibit empathy, which is an accurate and insightful awareness of the experience of another person. This means they are attempting to place themselves inside the patient's head, to feel his or her emotions. Illness can cause fear, despair, anxiety and a sense of helplessness. People in sickness need empathy, support and reassurance. Honest information about their condition should be provided to them in a compassionate manner, along with a listening ear to their concerns and preferences.


• The last characteristics is, they recognise that patients need as much of our medical skill as our caring capability. In the words of Francis Peabody, "the essential quality of the clinician is interest in humanity, for the secret of caring for the patient is in caring about the patient". Caring is not simply the manifestation of concern, empathy, and a willingness to talk with patients, it is also a capacity to talk and listen in a way that show concerns for a wide range of non-medical problems that can and usually accompany their illness. The healing power of holistic medicine encompasses both curing and caring, and healing may in a broader sense be possible even in those cases where medicine cannot cure. It can heal by helping a person cope effectively with permanent maladies.

Concluding remarks

To conclude, I would like to highlight two areas as food for thought. Firstly, the practice of medicine and the education of physician have for decades been oriented to the use of advanced technologies and the multitudes of pharmaceutical products. And medical training has been dominated by drilling in the acute care. To develop doctors who are more patient centred, ethically sensitive, and better versed in the management of chronic diseases, more emphasis is required on the humanistic dimensions of medical education. Students should be trained to be alert to problems elicited by the psychological and social conditions under which people live, which are increasingly understood to play an important role in illness and anxiety about illness. Rather than relying on values, attitudes and behaviours being handed down from generation to generation of doctors with senior doctors acting as role models for students and housemen, formal and solid ethical and communication skills training are needed in our medical education.

Secondly, we need more research studies examining the patient-physician relationship, particularly those pertaining to the effects of various types of communications and physician behaviours on outcome of care. As with psychotherapy, which could be regarded as a scientific art or artistic science, controlled empirical studies can advance the science of the art and still leave room for individual styles and creativity in responding to unique problems. This kind of research requires the successful collaboration between the clinically-aware social scientist and the social science-aware clinician.

Finally, the practice of optimally balanced medicine entails combining the life sciences with humanism. And empathy and kindness should be a mark of humane medical care. We should endeavour to keep medicine up to date, not only with scientific advances but also the society's changing circumstances and expectations. In all, physicians of holistic medicine should aim to amalgamate the skills and sensitivities of the applied scientist to the reflective capabilities of the medical humanist. This, ladies and gentlemen, is Medicine without the medicine.