The ‘practice’ of medicine

I like trusting the medical community. I like trusting that four years in med school, three or more years as an intern and resident working 24-hour shifts, several years as a fellow engaged in a specialty, and day-to-day experience with all kinds of patients make doctors knowledgeable, skillful and fully capable of curing disease.

Of course, that scenario works in a lot of cases. But not always, especially when it comes to cancer.

My science-medical writing course at Hopkins, Medicine in Action -- where cardiologists to oncologists spoke about the challenges of providing quality health care -- taught me many things. Chief among them:

1.  Avoid hospital admissions if you can.
2.  Avoid all unnecessary surgery.
3.  Remember that medical care is as much an art as a science.

I learned that while it's important to trust your physicians, you can't expect them to know everything. Medicine is still full of mystery.

One of the first jobs a doctor must do when he or she meets a new patient, I learned, is put together a reliable narrative, or story, for that individual. What brought this patient to the hospital or clinic? How does the patient describe his or her symptoms? What is the level of pain, if any? What medications is he or she taking? What can the doctor observe from visible physical symptoms and the patient’s state of mind? Does the patient have a history of illness? What did he or she neglect to mention? All of this requires an ability to listen attentively and ask the right questions.

What do vital signs, blood work, x-rays, scans, biopsies, lumbar punctures and other evaluative tests show? Are the results conclusive? Do they align with what the patient is saying? After the doctor has what seems to be a consistent narrative, he or she can begin treating the patient.

Obviously, some illnesses and injuries are fairly straightforward: an ear infection, a broken bone, an abscess. Others are trickier to assess. Even when the doctor seems to have all the pieces, the problem can still be difficult to diagnosis. And despite knowing what the illness or disease is, it can be exceptionally tough to treat.

It took two biopsies and four scans over six weeks to diagnosis David’s cancer. We knew he had a 6-cm. mass in his sinus cavity; the MRI had told us that much. Still, we went back and forth several times as various otolaryngologists, oncologists and pathologists suggested first that the tumor was benign, then it was malignant, then it was benign again. Ultimately, it was malignant.

Finding a treatment that will lead to cure, even with a favorable prognosis initially, has proved equally challenging.

As much as researchers have learned about cancer, there’s much more to learn. What makes malignant cells start growing in the first place? Why does cancer recur after all indications show it’s been eliminated from the body? When you have two patients with the same disease receiving the same treatment, how come one responds and the other doesn’t?

The scientific answer to many questions about cancer is “we don’t know.”

“We aren’t sure” is the answer I get to some of my questions about why David’s tumor isn’t responding to standard treatment, why half of it is dead but the other half isn’t, and even why he’s experienced few debilitating side effects from the powerful drugs in his system.

I’m OK with that because I know David’s doctors are giving it everything they’ve got and are talking to other experts as they puzzle out his “story.” Meanwhile, it's an exercise in trial and error.

One of our instructors, himself a physician, shared a timeworn saying that’s a favorite among medical practitioners: “There’s a reason it’s called ‘practicing’ medicine. Doctors keep practicing until they get it right.”

© 2010 by Lorin D. Buck