I am most honoured by the opportunity to speak at the 17th Dr. Sun Yat Sen Oration, first because I can have my name associated with the Father of Modern China, second because Dr. Sun Yat Sen was a general practitioner and third because he was an alumni of my own medical school. On the other hand, I find it most challenging to have to measure up to the standards of the previous 16 Dr. Sun Yat Sen Orators, many of whom are my teachers and mentors. I shall try to build on their outstanding foundation.

The title of my talk is 'Life is short, art is long', which many of you know is a quote from Hippocrates.¹ There are two interpretations to this saying: The first is to mean that the professional life of a doctor is relatively short, 30 or may be 40 years, but the art of medicine can have a much longer lasting effect on patients and their families, our profession and our society. The other interpretation is that learning of the art of medicine is a long process that one's life may be too short for.² Hippocrates (460-377 BC) was a Greek physician more than 2000 years ago. He is known as the Father of Medicine because many of his principles in medicine still hold true today. As pointed out by Professor Michael Kidd in last year's Dr. Sun Yat Sen Oration,

Hippocrates was the first family doctor in history, who emphasized the need to treat the body as a whole and not just a series of parts. Although he tried hard to establish medicine as a science, he had always regarded the practice of medicine as an art and he said "..... as in all the other arts, those who practise them differ much from one another in dexterity and knowledge ..... "³

The art of family medicine

Medicine is the most artistic of all sciences, and family medicine is the most artistic of all medical disciplines. What is the art of family medicine? Like any other art, it is best appreciated through experience. I therefore would like to share with you the narratives of a few patients from whom I have learnt a great deal about the art of our discipline.

The art of listening and speaking

The first patient is Mr. Peter Pang, a 25 year-old computer programmer who has been under my care since the age of 12. One morning I received a call from his mother who told me that Peter collapsed at home and was admitted to the Intensive Care Unit of the hospital a few days ago because his potassium was very low at 1.8 mmoles/L. He was transferred to the general ward after treatment but the doctor said he needed to stay in the hospital because his potassium was still low. The doctor said that the low potassium could be due to thyrotoxicosis. However, Peter had signed the discharge against medical advice (DAMA) form and was packing his bags to leave the hospital that morning. His mother was very worried because the doctor said that it could be dangerous for Peter to leave the hospital and she asked me to persuade Peter to stay.

I talked to Mr. Peter Pang over the phone. He told me that he was confused by the doctor sometimes telling him that his potassium was too low and sometimes telling him that his thyroxine was too high (potassium and thyroxine sound very similar in Chinese). He was very scared when the doctor told him that he would be given radioactive iodine because he thought radioactive iodine was the same as radiotherapy and he did not want to lose his hair. I explained to Peter the difference and relationship between potassium and thyroxine, and told him the difference between radioactive iodine and radiotherapy. I reassured him that radioactive iodine would not lead to hair loss and I also informed him that he had a right to refuse a treatment without the need to leave the hospital. Mr. Peter Pang changed his mind about DAMA and stayed in the hospital for further treatment. As some of you might have guessed - Peter did not have thyrotoxicosis; further investigations suggested renal artery stenosis.

Doctors hear a lot from patients but how often do we hear without listening? The art of listening is to understand the meaning behind the words; a patient who says he wants to DAMA may actually be trying to tell us that he does not understand what is going on or that he is very scared. We also talk a lot in our daily work including the causes of diseases and side effects of treatments, but do we really speak to our patients? The art of speaking is to be able to address the patient's ideas and concerns. What is being heard and understood is more important than what is being said.

The art of healing

Mrs. Nancy Wan is a 48 year-old high school teacher who complained of persistent dizziness since an episode of acute otitis media two months before she consulted me. She had seen more than 10 doctors including ENT surgeons and neurologists. All investigations including magnetic resonance imaging (MRI) of the brain were normal. She was taking atenolol prescribed by a general practitioner who found that her blood pressure was high (150/90); piracetam, stemetil and librium prescribed by a neurologist, and ginko leaves recommended by a friend, but she was still dizzy.

As a family doctor, I explored the family background of Mrs. Wan and found that she was living with her husband aged 55 and son aged 20. Her husband retired several months ago from work as a clerk. He used to be a businessman but lost his business in 1998 when the economy was poor. Mrs. Wan was very worried that she could not work because she was the bread winner of the family although she was still able to cope with her work quite well. She found it increasingly stressful to get along with her husband who had become more irritable and critical since his retirement. She was afraid of upsetting him because she knew he was still very bitter about his failure in business. After an hour-long consultation, Mrs. Wan agreed to try an alternative treatment for her dizziness - to heal the sore in her husband by an open discussion about their feelings. At follow up two weeks later, the patient told me that she had a good talk with her husband addressing many sensitive issues that they had avoided many years and they had become closer. She still had a bit of dizziness but it did not bother her much and she managed to stop all her drugs except the ginko leaves and atenolol.

Symptoms may be manifestations of diseases but they can also be signals of a relationship problem in the family. The art of healing is to enable the patient to resolve the underlying problem, rather than just to sooth the symptoms superficially. The family doctor can do a lot by re-attributing the illness, finding new solutions, facilitating changes, and empowering the patient to heal from within.

The art of 'First Do No Harm'

The third patient is Madam Mong who was a 55 year-old divorced lady living with her youngest son. Routine health screening found that she had hypercholesterolaemia (TC=8.1 mmoles/L, HDL 1.89 mmoles/L). She was treated by dietary advice only because the estimated 10-year cardiovascular disease mortality was less than 10%. Her son was very concerned about her hypercholesterolaemia and supervised her diet closely. He insisted that Madam Mong had to cut down not only the fat and cholesterol in her diet but also the amount of rice that she took each meal. Madam Mong's weight reduced from 49 to 45 Kg in the three months following her diagnosis of hypercholesterolaemia.

Since she started her dietary treatment Madam Mong felt cold and tired, probably because of insufficient carbohydrate intake. She also became very depressed and had impulses of killing herself. She became so unwell that she consulted the hospital Accident and Emergency Department three times in one month and was admitted to the Psychiatric Department for 25 days on the third visit. After discharge from the hospital, Madam Mong had come up with an effective way of coping with her diet: She would eat what she liked and the amount she needed before her son came home from work, then she would eat as little as her son wanted her to over their dinner.

In 'The Portrait of Doctor Gachet' by Vincent van Gogh, Auvers-sue-Oise, 1890, the artist painted a foxglove flower as a symbol of medicine, which can save as well as kill lives. Medicine is very powerful. A medical label can turn a happy and well person into a sick patient. The treatment prescribed by the doctor can have a serious impact on the patient and her family. Something as benign as diet can do a lot of harm and may even lead to a fatal outcome. The family doctor must beware of the harm of medicine. In the art of 'first do no harm', it is important to remember Hippocrates' advice "it is more important to know what sort of person has a disease than to know what sort of disease a person has".¹

The art of caring

From middle age, we turn to an elderly patient, Mrs. Wai Tai who was a 70 year-old widow living alone in HK. She lost her husband in her early forties and brought up three daughters on her own by working as a hawker. All her three daughters had completed university education and immigrated to Canada. After obtaining their Canadian citizenships, her daughters applied for the patient to immigrate to Canada but pre-immigration health check showed a hilar mass on the CXR of Mrs. Tai. Mrs. Tai was referred to the respiratory physician who confirmed the diagnosis of an inoperable bronchogenic carcinoma.

Mrs. Wai Tai accepted the diagnosis well and she decided not to have chemotherapy. She was not afraid of dying but she hoped she could spend more time with her daughters. Unfortunately her visa application was rejected for failing the medical examination. What could the family doctor do? With permission from the patient, I wrote a letter to the Canadian Consulate asking them to give special consideration to the patient's visa application. Two weeks later, Mrs. Tai was granted an immigration visa on compassionate ground and left for Canada to unite with her daughters.

In the art of caring, I have learned that we can do much more than what medical technology can offer, if we try. A bit of extra work that may not be our duty or part of our job description; that may not pay at all, and definitely is not included in the management guidelines, but it can make a difference and can have a long lasting effect on the patient and her family.

Qualities for good art

There is no better way to find out what qualities are required to create good art than to learn from one of the greatest, if not the greatest, artists in history - Vincent van Gogh. Vincent van Gogh was a true example of "Life is short, art is long". He lived only to the age of 37 from 1853 to 1890 and his life as an artist was even shorter from 1881 to 1890.⁴ In a letter to his sister, Will, he wrote "I should like to paint portraits which would appear after a century to people living then like apparitions .....".⁵ As he had wanted and predicted, his art has lasted longer than a century and is likely to last forever.

Passion

The first and most important quality for good art is passion. Van Gogh was passionate about painting and he said "..... my aim in my life is to make pictures and drawings, as many and as well as I can; then, at the end of my life, I hope to pass away, looking back with love and tender regret, and thinking, 'Oh, the pictures I might have made!' .... ".⁶ Van Gogh created 864 paintings and an additional 1340 drawings in ten years. He was as efficient as the family doctor. He did not paint for money or fame. He sold very few of his paintings and continued to work when he was in poverty and sickness. In the year of 1889 van Gogh suffered greatly from his mental illness but it did not stop his art. He created 140 paintings in that year and produced some of his most famous pieces such as "The Wheat Field with Cypresses".

The practice of family medicine is hard work that does not make one rich or famous. It is the passion for solving patients' problems that drives the family doctor to work for long hours, to do the little extra things like counselling without being paid, to continue to improve, and to feel satisfied.

Practice

Many people think van Gogh was a genius born with the artistic skills. This was not entirely true, van Gogh actually worked hard to learn and practise his skills in painting. He often painted a series of the same object or theme in order to practise the different skills and ways of expressing his art. He described in one of his letters to his brother "I intend to make a series of them, and hope to do better ones than the first two. It is a method that I had already tried in Holland some time ago ....".⁷

Van Gogh had painted a series of 36 self-portraits from 1886 to 1889, many of them look similar but they also differ in their details. Practice is not a mere repetition of the same application of knowledge and skills. It involves reflection, improvement and development, so that one can perform better with each practice. Some people think six years is too long to train a specialist family physician. It may be so if the family doctor needs only to have the required medical knowledge and clinical skills, it is barely enough to enable adequate practice for the transformation of a technique into an art. Even for a genius like van Gogh, he had practised for six years since 1881 before he produced his first painting of the sunflower in 1887.

Imagination

In a letter to Emile Bernard, van Gogh talked about the importance of imagination for an artist. He said "The imagination is certainly a faculty which we must develop, one which alone can lead us to the creation of a more exalting and consoling nature than the single brief glance of reality".⁸ One of van Gogh's most famous paintings 'Starry Night' was created in June, 1889 when he had to be confined indoors in the asylum in Saint Remy most of the times.⁴ The painting was done from memory and imagination, which added much more depth and perspectives to the art.

Family doctors are presented with problems that have no boundaries, for which we often have to find new solutions that medical science alone cannot provide. There may be a limit on the available treatments of a disease in medicine but there is no limit to the care that the art of family medicine can offer to patients if we use our imagination.

Uniqueness

Everybody would think of the sunflower when he/she thinks of van Gogh, his paintings of which had made him famous throughout the world. Van Gogh indeed identified the sunflower to be uniquely his in a letter to his brother "You know that the peony is Jeannin's, the hollyhock belongs to Quost, but the sunflower is somewhat my own.".⁹ He was not the only artist who painted the sunflower but he was unique in capturing the flower not in its full blossom but at the time when it is withering away. His unique colour combinations of yellow, green and blue had made his art most memorable.

Research has found wide variations in the practices between family doctors; some critics see this as a problem of lack of standardization of care, but those of us who understand the art would know that this is a reflection of the uniqueness of family medicine to tailor for the unique need of individual patients. There are many factors that influence how the family doctor applies the medical science to each patient, which are unique to the patient and the context that are not identifiable by statistical regressions.

Art is complex

"Art is Complex", as van Gogh's brother had reflected on the work of the artist, "His ideas cover so much ground, examining what is humane and how one should look at the world, that one must free oneself from anything remotely linked to convention to understand what he was trying to say...".¹⁰ How can one describe the complexity of an art in simple words?

We sometimes feel frustrated and even apologetic for not being able to articulate the work of the family doctor in a few words or even in an essay. We would not be discouraged if we remember the complexity of family medicine. How can we generalize our work when the care for each patient requires a complex integration of physical, psychological and social factors, and a delicate balance between benefit, harm, patient autonomy, cost, fairness and equity?

Conclusion

I started my talk with a quote from the Father of Medicine, I would like to conclude my presentation with a quote from the Father of Family Medicine, Professor Ian McWhinney, who said "Our value to medicine lies in the differences ....".¹¹ Family medicine is different from the other medical disciplines in how it expresses the science of medicine in the care for a person who is ill and not just to treat a disease. Different people need to be treated differently even if they have the same disease, the same person with the same disease may need different care at different stages of the illness or in a different context. In order to make a lasting difference with the art of family medicine, we need to be passionate for our work, keep practising, use our imagination and preserve our uniqueness.

I have learned that the art of speaking is to provide one take-home message. The message from Professor Michael Kidd was 'to make at least one patient cry each day', and that from Dr. Y.T. Wun was 'to make at least one patient laugh each day'. My message is 'to make a difference for at least one patient each day'. With this, I would end my presentation and thank you all very much for your attention.

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* This paper was presented as the 17th Dr Sun Yat Sen Oration on 28 May, 2006.
+ Note : All patient names and personal information presented in the oration were not real.

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References