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Literature and medicine



I address a rather difficult, yet fascinating topic: that of 'literature and medicine'. Difficult subjects are challenges, which we can address in a presentation of this nature. Medicine and literature may appear divergent in many ways but let me weave an interaction of professional interest with these subjects.

You will learn about the wider sphere of challenge that medicine offers us. To understand any combination of subjects, we have to look at their histories. Understanding the background gives one the mechanism of understanding the current mechanics. Only then can one propel into the future.

Today, you stand at the cross road of modern medicine. The concepts of problem based learning (PBL), patient-oriented evidence that matters (POEM) and evidence-based medicine (EBM) are new. Against these methods you have detailed didactic lectures of yesteryears. A thorough grilling in anatomy, physiology and biochemistry took up to 18 months at medical school in my time. Science and technology have advanced at a rapid pace in the last 20 years. The volume of learning has become even more burdensome. Study has become overwhelming.

What was important and practical? Was it volumes of anatomic knowledge or should it be practical methods to deal with common problems in practice? The seeds of EBM and PBL mushroomed. Clinical-based learning became the order of the day. The net result was a paradigm shift in the area of medical education. Who is a better graduate? Who is a better physician? The evidence is still not available. It will possibly never be known. The literature is still amiss.

The literature is amiss on a lot of issues. Medical literature when recorded is very important as it demonstrates the ascent of medicine from humble beginnings. The ancient art of observation, collection of data and drawing up an hypothesis is topical and an inherent part of any scientific study. When the hypothesis explains actual happenings it is accepted or we go on another wild goose chase. Documented medical literature remains constant and explains the rationale of man's thinking as we weave our way through life. This reliance on documentation serves as a platform on our thinking, its directions and shifts in the thinking process to what it is today, and possibly gives us a glimpse of its potential in the future. Now that we have tied up the two components of this presentation, let's proceed in some orderly manner

A history of medicine

The Greek physician Hippocrates is the father of medicine. I say to you, documented medical literature is the mother of medicine. Approximately 500 BC at the height of the Greek civilization, Hippocrates practiced medicine amongst his other specialties: philosophy and arts. Records of his Treatise were documented, to be passed onto generations of physicians. At the fall of the Greek empire, the Romans took over reigns of power and the centres of medical excellence shifted to Rome and later to Europe. Islamic influences in medicine followed with aspects of preventative care (clean water, central sewage disposal and asepsis practiced) in greater Mesopotamia.

Only after the 17th century, European civilizations arose from progressive barbarianism; names like Joseph Lister, Louis Pasteur, Madame Curie and Alexander Fleming entered the medical arena and literature. Watson and Crick discovered the DNA sequence in the early 1960s and this led to clear understanding of our genetic make-up. Gene mapping has now followed. We are now ready for human cloning, genetic engineering and genetic intervention in non-communicable diseases, including cancer prevention.

For a moment let's look before Hippocrates. The witch doctor, our true ancestor, was close to nature and god. His remedies included concoctions of roots, bark, leaves, fruit and the like. The mumbo-jumbo chants healed just as well. The injured, hurt and disabled may or may not have benefited. Yet the emotional and spiritual needs were taken came of by this ancient practitioner.

The area of emotional/mental/spiritual health is no better taken care of today than it was in prehistory. Our physicians of today have delved into the science of medicine. They have uncovered the genetic code and have the most powerful of antibiotics, yet fail to unveil the mysteries of the psyche, emotion and spirituality. Our biomedical model of disease seldom takes into account holism in medicine. Our training remains grossly deficient in this area. The bio-socio-medical model attempts to address some of those deficiencies. Specialty-based pathology and separations make holistic treatment almost impossible.

In the community we need to address the wholeness of existence. Then again not all is physical. A lot of the ailments are emotional and spiritual which we are not trained to handle. We have no special counselling skills so we are truly deficient, lost, and we withdraw after issuing our sick sheets and prescriptions for needless antibiotics, sedatives and non-steroidal anti-inflammatory agents.

While on the topic of prescriptions, note that as medical personnel we need to identify the true need for antibiotics. We have a wide array of potent antibiotics and we use them without compassion to consequences. Like the American GI, we hold a loaded machine gun, ready to discharge even at a mirage in the desert. We are contributing to the species-jumping of germs like the SARS virus and avian flu virus. We see the re-emergence of tuberculosis associated with HIV. Who is winning the germ warfare? Definitely we are not winning from our indiscrete usage. We are compounding the growing problem of drug resistance.

Today you stand at the crossroads of 'specialty' in medicine. As students of medicine, a range of specialists has groomed you. The novelness of technology and science are encompassing. The equipment around you remains unique and far-reaching. You are becoming totally dependent on smart machines. Lest you forget, emotional ill health as a result of stress in life can give rise to major physical/psychological stress and sickness. We need to able to address this in our school from day 1 in our PBL/POEM curriculum.

Beware! You face a glut of legal practitioners. The influence of the Internet on a population who thrives on information and increasing self-centeredness is worrying to say the least. Even a misadventure can prove litigatious. Professional defamation becomes truly real, medical indemnity insurance a necessity, and the practice of defensive medicine the end result. Medicine was never intended to be practiced as such.

What then may you ask was it intended to be? Primary care in the community is what medicine should be. Listening to your people, looking them in the eye and teaching them better ways of surviving the 21st century. Primary care is about holistic healing. Not just the cure of physical conditions but also of the psyche and spirit. Too many of us leave the domains of medical school armed with a lopsided view of life. Physical ailments form but a small fraction of ill health in society. We are ill prepared as physicians to tackle the emotional and spiritual needs of our patients.

Let's move to the documented medical literature.

The mother of medicine

Our attempts to seek established knowledge are based on retrieval of relevant medical literature along with clinical appreciation of the sick, diseased and the dead. Based on literature, we learn of previous methods of therapy and their clinical response. Literature may in fact be anecdotal thence the knowledge, suspect. The evidence of therapy may be hard to come by or difficult to determine. In all this activity lies the quest for knowledge: be it to heal and to determine the evidence of its degree of efficacy or its uselessness.

A substantial amount of your EBM will prove futile soon after your graduation. Art will supercede the science of your medicine. The literature of medicine remains the only constant, which identifies the changes in practice.

On a personal level

In my own practice, literature continues to play a dominant role. For three years after graduation I never lifted a book, strangely. I was overwhelmed by the practice of medicine, raising a family all too quickly and pressures to work as an obstetrics registrar. Eighty hours a week was backbreaking even 26 years ago. Fourteen years ago in private practice for the first time, the need to refresh arose. Being dipped in ice water was the sensation for the first time in primary care, solo practice. This was a new ball game. I had no background in handling emotions and spiritual ill health. I was much into the biomedical model of illness where emotions and spiritually had no place. The learning curve was great and tedious till it has become second nature to look at each patient and ask oneself, what is this patient's need? What is thinking behind the patient's question? What is the unmet need?

About the same time I took on a passion for family medicine and was thrust with the editor's role by the fledgling Fiji College of General Practitioners. Learning to edit the Fiji General Practitioner 11 years ago was my formal entry into the world of medicine literature. There, I learnt the art behind the science. Learning to read, edit, and peer-review articles broadened my horizons on all facts of medicine. As a natural progression, with the development of the Asia-Pacific Journal of Family Medicine I was called to serve on the Editorial Board to peer-review, edit and contribute articles at the Asia-Pacific Forum. Professional accolades followed, in the form of being awarded 'One of the 2000 academics of the 20th century' by the Bibliographic Society of Cambridge University.

The World Organization of National Colleges, Academies, and Associations of Family Medicine awarded the Global-Doctor Award in October 2003 for outstanding work in the area of medical publication.

This is how medicine and literature can be blended in one's life. Now I plan to blend in wider literature by understanding people like Dr Anton Chekhov.
1 Truly, medical literature records developments in medicine. Engaging both mother (medical literature) and father (medicine) in the act, results in good progeny (the practitioner). That would be one's aspiration as a newer graduate.

Empowered with holism you may truly practice medicine as it was intended. With maturity comes empathy and compassion, building trust as you progress in your own professional life. Ready to make a difference in the global village.



1 1 Cope J. Doctor Chekhov: a study in literature and medicine. Chale: Isle of Wight Cross Publishing, 1997.