| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Eur J Cardiothorac Surg 1999;16:S2-S5
© 1999 Elsevier Science NL
Emeritus Professor of Surgery, Washington University School of Medicine, St. Louis, MO, USA
Key Words: Physicians • Teachers • Students
Dr. Max Cowan, a former Professor of Anatomy at Washington University School of Medicine in St. Louis, tells this vignette. A faculty member died and willed his body to the school. There was a sealed envelope, along with a covering note requesting that when his body was to be dissected, the envelope be given to the students assigned to his cadaver. Dr. Cowan opened the note and read the following: ‘Dear students: the greater part of my professional life has been devoted to trying to teach medical students something. This will be my last attempt.'
This summarizes well what we physicians do – learn and teach, teach and learn, – all for the welfare of our patients. These are life-long tasks for every one of us: forging the links not only between teachers and students, and between doctors and patients, but also among colleagues worldwide.
I have had the pleasure of visiting the countries of the pacific rim on a number of occasions, but China only once, that in 1981. My wife and I look forward with eager anticipation to our mainland trip right after this meeting. It seems to me that we cannot let this opportunity to visit this great country pass without making a few observations and predictions. Winston Churchill said it is difficult to look further ahead than you can see, but I will take that risk. After all, at my young age there should not be that many helpings of humble pie to consume if my predictions prove erroneous.
Through the efforts of Dr. Wu Ying-Kai (Fig. 1), a 5-day international symposium on cardiothoracic surgery was held in Beijing in September 1981. It was said to have been the first gathering of this type in the history of Chinese medicine. There were 54 presentations by 37 lecturers, 17 of these from the People's Republic of China, and 20 from America, Canada, Europe, Scandinavia, and South America. Dr. Wu is the visual personification of the oft-quoted Chinese proverb: ‘To plan for a year, plant rice; to plan for a decade, plant acorns; to plan for a century, teach men'. Much of what little I know about Chinese medicine I learned from Dr. Wu, and as I came to understand the ‘whys' the more sense the ‘hows' made. Let me give you a few examples.
|
In the meantime, how have we fared in the West? Since the incidence of esophageal cancer in the United States is 5/100 000 instead of the more than 20/100 000 seen in China, we have, in our wisdom, decided that the cost-benefit ratio for mass screening is too steep. Hence, we persist on focusing on such important aspects of the disease as to whether MRI scans can correctly detect metastases. As a result, overall 5-year survival rates have only increased from 5 to 10 % in the last 2 decades. Is there not a lesson to be learned from this Chinese proverb? ‘The superior doctor prevents sickness; the mediocre doctor attends to impending sickness; the inferior doctor treats actual sickness'.
Another example is the barefoot doctor – better termed dispensary attendant – a concept poorly understood in Western thought. The need for them arose because of a few basic statistics. China occupies roughly the same latitude and has the same land mass as the Unites States, yet has a third less tillable soil, and four times the population to feed and care for. The brigade system with the so-called barefoot doctor at the entry point for medical care was a brilliant solution to what seemed an insurmountable problem. The term ‘barefoot doctor' is really an unfortunate misnomer that arose because their ranks were made up of peasants who were given basic medical training, and who worked barefoot in the rice paddies a half day, and then ran the dispensary a half day treating minor complaints and triaging sicker patients to hospitals and medical centers. The importance of the concept was not whether high quality care was available, but that every community, no matter how small or isolated, had a place where the sick person could go and receive medical attention. In the United States, where we embrace the concept that only high-end technology will suffice, we have for decades and with little success been trying to locate and man treatment centers of this type in the inner cities and the rural areas of our country.
At one time it was estimated that there more than 1 000 000 barefoot doctors in China, and it is interesting that this number has been steadily decreasing, not because the idea is not a good one, but with economic change the dispensary attendants have found that they can make more money farming. And this is occurring at a time when in the United States, again because of economic conditions, the services of the non-MD health care workers – nurse practitioners, midwives, physician assistants – are in great demand at the medical entry level, often to the purposeful exclusion of physicians.
Another insight I developed from my acquaintance with Dr. Wu is the importance of keeping an open mind on all subjects, but particularly on matters of health. I lost my intolerant attitude toward acupuncture when we witnessed at the Beijing Tuberculosis Hospital a female surgeon performing a left upper lobectomy on a 35-year old woman, whose only ‘anesthesia' was a needle inserted in the meridian of the right forearm. Whether so-called modern medicine considers this witchcraft or a mental tour-de-force is beside the point. What is important is that this technique has been with us since 2600 BC. It was developed during the reign of the third Emperor of China, ‘Huang Di' (the Yellow Emperor), who authored a medical textbook that made him the Hippocrates of China. Something this enduring must have value.
The same principle of ‘worth in longevity' can be applied to herbal medicine. Chinese physicians practicing traditional medicine have learned to work in concert with physicians using modern or ‘Western' methods. The roots and bark, berries and leaves that been used for centuries to treat medical ills should not be cast aside as worthless in a more sophisticated world, but rather should be plumbed even deeper for their yet undefined secrets. Confucius himself, around 500 BC, had the last word on this subject: ‘because newer methods of treatment are good, it does not follow that the old ones are bad: for if our honorable and worshipful ancestors had not recovered from their ailments, you and I would not be here today'.
One final example from the lessons I learned from Dr Wu relates to their mental approach to the care of the sick. It has been my observation that the people of Asia treat their fellow human beings with great respect, and, as Confucius just told us, the elderly and those that have passed on are accorded a special, almost reverential status. We obviously see elements of this attitude in Western culture, but I do not believe to the same degree. The dignity and respect accorded those that have passed on is present in great abundance in the room of the patient near death. The nuance to which I am referring is expressed well by Phillips Brooks: ‘Duty makes us do things well, love makes us do them beautifully' and by J. Engelbert Dunphy: ‘Death holds no fearful threat. Living without life is hell. Death is natural; it may be just; it is often easeful and merciful; it ought always to be dignified. Who knows, it may be paradise'.
There is an invaluable little book written by Lois Wheeler Snow, entitled ‘A Death with Dignity'. The 148-page volume tells the story of the slow and painful death from carcinoma of the pancreas of her husband, Edgar Snow. The Snows spent many years in China, and have written books and articles about the country. She tells of their bitter, lonely experiences in clinics around the world before they decided to return to their then home in Switzerland for his last days. Then the Chinese came. They had heard of his illness, and wanted to take care of him. In paraphrase, she says: When the Chinese came, they shared all information: doctors, nurses, the patient and the family discussed problems openly. Medical personnel were freely available to the family. The patient received companionship whenever he wanted it. Emphasis was on the person, and the family, as well as the incurable illness. Then Mrs. Snow concludes with what is certainly my favorite quotation, and one that in my judgment merits a place in every physician's office: ‘There is yet a limit to technology, there is none to humanity, beyond our own making'.
These are a few examples of the wonderful insights we learned from Dr. Wu during our visit to China almost 2 decades ago. The external face of China has surely changed, but my guess is that the important things Dr. Wu talked about have not. Eastern Culture and Eastern Medicine can certainly benefit from many things imparted by the West, but I believe the West has just as much to learn from the East. Perhaps more.
For the next few minutes I would like to play Nostradamus. Benjamin Disrali in 1867 said of his times, ‘Change is inevitable. In a progressive country change is constant'. I predict that we are on the threshold of the greatest global restructuring in history. In the business world these days the buzzwords are merger, consolidation, and bigger is better. There is no segment of the economy or social order that is not caught up in this rush to put away petty differences with rivals and join forces to survive and thrive. Examples are part of our everyday life: financial houses, media giants, clothing stores – add your own illustration. And the medical industry is caught up in whirlwind fashion, so that small supply houses, small hospitals and solo practitioners are all as endangered as the Bengal tiger.
Nations, too, are involved with the process. Like all of you, I have watched with fascination as the European countries, each with its own proud heritage of customs and traditions in place for the greater part of two millennia, are coming together as a single unit, to forge a whole that will be infinitely greater than its parts. We have also seen a bellwether of this activity in medicine, where in a scant dozen years The European Association for Cardio-thoracic Surgery has become the spokesman for our specialty in that part of the world. So the thought progression here is obvious. It is not difficult to envision the day when interdependence across all the elements of modern society will be centered in the three land masses separated by the great bodies of water on this planet: They are now called Europe-Africa, North America-South America, and Asia-Australia. Some day in the distant future each may even adopt for itself a separate new name.
There will be many problems to be solved during this evolution, and many barriers that have been in place since the beginning of recorded history will need to be removed. Without question the greatest of these is the ‘confusion of tongues' initiated at the tower of Babel. But as the world becomes smaller and different heritages are mixed one with the other by sonic travel, and with every computer on earth linked together, this problem surely will resolve itself over the fullness of time. Except we want to hurry it along faster than that. Perhaps the world medical community will lead the way. During my lifetime I have seen the German language, once the standard for medicine, replaced by English, and have seen medical meetings all over the world discard the translator earphones and adopt English as the official language for their conferences. This trend I don't believe reflects any particular love for the English language, but is more likely rooted in the fact that most countries of the world except the English-speaking ones have long realized the importance of being conversant with a number of languages. Therefore, they have made learning these tongues a serious and sizable part of every child's education from kindergarten on.
The Chinese language represents one of the greatest challenges. It is said that Chinese culture made four great contributions to mankind: paper, movable type, compass, and gunpowder. This certainly must be a judgment that originated in an ignorant West, since, for example, a surgeon named Hua Tuo in the second century AD was using anesthesia induced by a Chinese herb called ma fei san for performing major abdominal operations and amputations. But it is unfortunate that when movable type was invented, these same individuals did not apply themselves to making the characters simpler and thus easier to carve and fire in the clay molds that were used. So the Chinese language is indeed still a barrier for the rest of us, and we need to work hard to resolve this dilemma. Mark Twain recognized the elements of this problem when he said, ‘Be careful about reading health books. You may die of a misprint'.
But you must know that the three land masses are not the end of the story. This progression can only reach its goal when we truly have attained what, in 1940 and far ahead of his time, Wendell Willkie called, ‘One World'. When that happy day occurs, my hope and prayer is that physicians all over the world can willingly meet the standard asked of us by Norman Cousins in 1940, when he wrote: ‘To practice medicine at a time when the earth has become a single geographic community calls for an enlargement of the Hippocratic oath. In today's world the physician must make his commitment not just to the individual but to the institution of life. To the extent that medical societies are concerned only with professional questions, they restrain physicians from involvement in ethical issues. Insulated in that manner from his central role, the physician can trail happily after illness while ignoring his obligation to help humanize society and to make it safe and fit for human beings'.
A big order? Of course it is! But the attitude of physicians all over the world, and I'm proud to say, cardiothoracic surgeons in particular, is epitomized by this quotation: ‘Those who say it can't be done should never interfere with those that are doing it'.
 |
Footnotes |
|---|
Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
