I welcome you to the company of educated women and men who have chosen, as their life's work, the alleviation of pain, the amelioration of suffering, and the avoidance, to the extent possible, of premature death through the practice of human medicine.
You join a long line of physicians, stretching backward and forward in time, who are committed to these goals.
The chairs you are seated in were prepared for you by the Hippocratic physicians. This group of individuals, working approximately from 430 to 300 B.C.E., revolutionized our understanding of medicine. According to the prevailing practice of the time, prior to the Hippocratic physicians, sickness was treated by prayers to the gods. Aesculapius was the principal god of healing. Rituals in the temples of Aesculapius included a belief in the power of snakes. The god was said to hold a staff about which a healing serpent was wound. From this image we inherit the modern symbol of medicine, the Caduceus. For the priest, the primary focus was the therapeutic dream. The patient reported the dream to the priest who, in turn, gave the patient instructions as to the course of action to be followed to be healed.
In contrast, the Hippocratic physicians believed that balance must be obtained among the four fluids: blood, yellow bile, black bile, and phlegm. If any of these four fluids was out of balance, that person became ill. This view of the four fluids was, obviously, ultimately discredited. The Hippocratic physicians, however, brought us several innovations in medicines which are still with us today. To wit:
- They kept accurate notes and passed these clinical notes onto their students.
- The Hippocratic physicians actually examined patients. They studied bodily secretions, evaluated the patient's temperature, the color of the skin, and other physical characteristics. They took medical histories.
- Because the physicians kept such precise records, they were the first to be able to give patients a relatively accurate prognosis.
The Hippocratic physicians also gave to us, as a bequest, a code of ethics which you will learn more about later this week. They generated the famous book, The Aphorisms of Hippocrates. This is a collect of pithy, sententious statements about how to care for sick people and how to live a moral life. The most famous of these aphorisms is the first: "Life is short. The Art is long. Opportunity is fleeing. Experience is delusive. Judgment is difficult." Because the word Art is capitalized, it refers to the "Art of medicine". You may, therefore read the aphorism as follows: "Life is short. The Art [of medicine] is long. Opportunity is fleeting. Experience is delusive. Judgment is difficult." If we break there five phrases down into their component parts, there is much to be learned.
"Life is short. The Art is long." This means that no doctor can learn everything that he or she needs to know in one lifetime.
"Opportunity is fleeting." This means that the patient will come to see you at a particular point in his or her disease. You will only be offered a small window of opportunity with which make a diagnosis.
"Experience is delusive." This means that your individual experience as a physician can be deceptive. You must be cautious about thinking that you've learned something from "that interesting case I recently saw." You will now be called upon to use evidence based medicine. You will use statistics to combine the experience of thousands of patients and doctors.
"Judgment is difficult." Every physician must learn judgment. You must learn when to operate and when not to operate, when to call in a consultant, and which therapy is best for the individual patient.
I also wish to remind you that the chairs in which you are seated were prepared for you, after Hippocrates, by Vesalius and Morgagni. In his magisterial work, On theFabric of the Human Body, published in 1543, Andreas Vesalius taught physicians to stop relying on the traditional, and in many respects, flawed natural philosophy teachings of Aristotle and Galen. He recommended that we begin to inspect the human form directly with our own eyes and, most importantly, with our own hands. In 1761 Giovanni Morgagni published his book, On the Seats and Causes of Disease. Morgagni correlated symptoms of disease with anatomical lesions uncovered at autopsy. In this profound lesson, he taught us that progress on the diagnosis and treatment of disease hinged on findings disclosed during post mortem dissection of the human body. Distinct from the Hippocratic physicians, who highly prized observation of exterior signs of disease but showed little interest in the interior of the human form because the humoral theory did not require an understanding of internal anatomy, Vesalius and Morgagni were grounded in the correlation between structure and function. They taught us that if we do not know how the human body is put together we will be ill equipped to discern its action. If a patient is generally ill then somewhere in his or her body there is an organ, tissue, cell, or molecule whose structure is abnormal. In contrast, someone with organs, tissues, cells, and molecules that are all put together properly cannot, in an epistemological sense, be ill. So complete is the dominance of the structure/function paradigm in medicine that the term "internal medicine" has, with the exception of rarified areas of dermatology, become redundant.
It will be easy to be seduced into the notion that if you have mastered individual disciplines in medicine such as biochemistry, anatomy, physiology, pediatrics, obstetrics-gynecology, surgery, you will understand medicine. You must be cautious about putting the individual disciplines of medicine into distinct bins. They are, rather, inherently cross disciplinary.
The notion of interdisciplinary knowledge was bought home to us, almost 40 years ago, by one of Duke's most distinguished faculty members. He wrote that the
"unifying concept that all life is understandable in chemical and physical terms has made a mockery of many of the lines which separate the biological disciplines. In due time we will have to reorganize the life of the University and take cognizance of this. The barriers have fallen intellectually “ we now have to remove them in terms of administrative management these problems [generated by technical progress] require solutions and decisions which should never be left to scientists. Scientists are very competent in the laboratory but they have no right to make the larger decisions which affect mankind. It is imperative in the University to create interdisciplinary operations, crossing the life sciences with philosophy, religion, government, and sociology, because these greater questions will have to be resolved. If they are not resolved deliberately, the events will run away with themselves; and whenever that happens, you can be certain mankind will suffer."
Philip Handler's, Duke's Chairman of Biochemistry in 1968, ideas remain worth thinking about today.
You are all here because of acts of faith and trust. You must have faith and trust in your own abilities and on the importance of medicine in order to commit yourself to this calling. Your families have faith and trust in you because they have exerted great effort to put you where you are today. You will, however, have one more act of faith and trust to pursue which will be the most profound of all. You will wake up one day and discover a fellow human being who will place faith and trust in you because they define you as "my doctor" and themselves as "your patient". This will be a moment of great excitement. Treasure it. I remind you, as Seneca wrote around the year 60 A.D. "People pay the doctor for his troubles; for his kindness they still remain in his debt."
I welcome you to the company of educated women and men who chose to devote their lives to the relief of pain, the amelioration of suffering, and the avoidance, when possible, of premature death. Remember that "Life is short. The Art is long. Opportunity is fleeting. Experience is delusive. Judgment is difficult."
Godspeed on this part of your journey, ladies and gentlemen.