God and the Imperfect Practice of Medicine

Among my favorite statistics are those that a) fully comport with my worldview or b) those that I simply make up. The following stat belongs to the latter category:

85% of life’s anxieties would be ameliorated if we knew better how to cope with uncertainty and imperfection.

Impressive, right? Yep. Straight out of my noggin.

But it’s kind of true.

Just think…think about how much we don’t know or can’t know. And think about all of the imperfections we have to deal with in ourselves or in others. It is staggering.

And yet we do it. Day after day. We live our lives fairly successfully in spite of our uncertainty and imperfection.

I practice internal medicine. While seeing patients, I also teach medical students and residents about history gathering, physical examination, and the critical thinking that goes into discerning a diagnosis and selecting treatment. In effect, I attempt (albeit, imperfectly) to pass on the art of healing. To do this, I must pay attention to studies published daily about how to provide good medical care and apply them to the patient in front of me using wisdom and common sense.

Now, the studies come in all shapes and sizes: prospective and retrospective, randomized and placebo-controlled, case-control and case series, blinded and unblinded. The gold standard study is a prospective, randomized, double-blind, placebo-controlled trial with “hard end points” (like death, heart attack, or stroke instead of “surrogate markers” like improved angiograms or biomarkers). Funding comes primarily from the government or private industry. It is mind-boggling. Every year, in a field of immense complexity with nothing less than millions of human lives at stake, billions of dollars are spent to find the right answers for the optimal patient care.

And do you know what?

We can still get it wrong.

In spite of the greatest minds, immense resources, and gold standard trials, we don’t always get it right. Notwithstanding the genius of the scientific method and a magnificent corpus of data, our studies can fall apart or contradict one another. Even some of our best studies have outcomes that can’t be reproduced when a subsequent study is attempted.

G.K. Chesterton once observed the limitations of human wisdom in this excerpt from his poem, The Convert:

The sages have a hundred maps to give

That trace their crawling cosmos like a tree,

They rattle reason out through many a sieve

That stores the sand and lets the gold go free.

Sheesh.

Does that mean we should be cynical, stop our meds, refuse vaccinations, and adopt a Luddite worldview vis-à-vis modern medicine? Abandon hope all ye who enter here?

Of course not.

Clearly, antibiotics have saved lives. Without question, surgery has pulled people back from the abyss. Undoubtedly, chemotherapy has lifted the death sentence of many an untreated cancer. Life expectancy has increased and infant mortality has gone down. And all of this is thanks, in good part, to the lumbering, squabbling, self-contradicting yet brilliantly earnest field of medicine. The fact that, based on the latest literature, I am one day recommending a particular medicine and the next I am advising to back off from it strangely reassures me. Clearly, I am not assured that medicine is perfect or infallible. Instead, I am reminded that medical science is largely honest in openly pursuing good care, yet willing to own when it is wrong. If the practice of medicine ever ceases to have a little egg on its face, then that is the time when I will start to become worried.

Given the fallibility endemic to the science and practice of medicine, we, as practitioners, need to be humble, and we, as patients, have to be clear-eyed in our expectations. As practitioners, we need to appreciate the water’s edge that distinguishes between knowledge and conjecture. We need to recognize where studies apply to populations, but perhaps not to this particular patient. We need to push away from the computer, lean into our conversation with our patient, and tap into the palpable common sense that transcends naked data with this patient at this moment. We need to think clearly and give a damn.

We need to be humble and, consequently, more human.

Every physician (frankly every clinician) knows what I am talking about. When you have been in this business long enough (like many other human endeavors), you get to see behind the curtain. It is a brilliant whirlwind of math and science, theories and guidelines, algorithms and models. But most of all it is a gloriously ordinary, supremely imperfect human endeavor. It is a beautiful exchange of one person trying to help another.

If we can grapple with uncertainty and imperfection (which, quite simply, isn’t going to go away), we can find greater fulfillment, greater hope, greater patience, and perhaps most of all, greater humanity. Walt Whitman said it well in his poem When I Heard the Learn’d Astronomer:

When I heard the learn’d astronomer,

When the proofs, the figures, were ranged in columns before me,

When I was shown the charts and diagrams, to add, divide, and measure them,

When I sitting heard the astronomer where he lectured with much applause in the lecture-room,

How soon unaccountable I became tired and sick,

Till rising and gliding out I wander’d off by myself,

In the mystical moist night-air, and from time to time,

Look’d up in perfect silence at the stars.

The science and practice of medicine are not unique. The limits of any human industry or endeavor will always be there. Always. But perhaps, in knowing this, we will wander off by ourselves and look up in perfect silence.

And perhaps, just perhaps, we will better know God.