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• W2048492798 abstract "About two months ago, a second-year medical student e-mailed me to ask about the value of humanities courses. As a humanities major in college, he questioned the overwhelming dominance of required medical sciences in his preclinical classes. Science is, and must be, the mind of medicine: It is what differs us from quacks and what patients depend on for their future well-being. Yet, some say we should, in addition, teach humanities in medical schools because the applicants preferentially selected for admission are science-techno-geeks. But that is not true! Among you are musicians, poets, historians, dancers, artists. You come from many and diverse backgrounds in culture, religion, and language. These “humanities” are not extinguished in medical school, though some may be sidelined for a while. Still, shouldn't we have required classes in the humanities to emphasize to our students that study of the humanities makes people better doctors? There is not much evidence that works. Germany in the first half of the 20th century was a highly educated nation in literature, philosophy, and music. And, as a medical school professor in Tel Aviv wrote later, what this allowed Nazi doctors to do in the death camps was march their victims to the ovens with prisoner orchestras playing Handel and Bach to quiet them on their way. Nevertheless, I propose to you that, although science is the mind of medicine, the humanities are indeed its heart, but for your education in this, your patients and their families are the best teachers you will ever have. You will witness and be part of great events in human lives by being with and touching, listening, and talking to your patients. Each one has a history and is a part of history. Their stories—of courage, love, joy, fear, loss, death—echo the themes that great writers of the past used in their famous books, plays, and poems; composers in their operas and ballets; and artists in their finest creations. Medicine is, I think, the greatest of all humanities. In 1900, life expectancy at birth of an American man was 48 years, and of a woman 51. By 2012, it was 76 years for men and 81 for women, largely because of medical science: public health, vaccines, antibiotics, the causes, detection, and therapies of malignancy, cardiac and lung diseases—and more, much more. What greater humanity could there be than one that has given human beings nearly 30 more years of life? Dr. Jock Murray, from Nova Scotia, said, “Medicine is a human endeavor that uses science as a tool.” An Englishman, Francis Bacon (called the Father of the Scientific Method) designed that tool over 400 years ago, replacing centuries of medicine's reliance on the authorities, Aristotle and Galen in the Western world. Bacon's method was based on inductive reasoning in which you ask a question (I wonder why … ?) and form a theory—a hypothesis—to answer it (Could it be … ?), then seek evidence to support or refute that hypothesis. This requires observable phenomena that can be isolated, described, measured, and numerated, then tested with variables and controls. Precise details of the experiment and results must be written up and made public so other scientists can review and/or repeat the study, and perhaps make changes in, or even overthrow, the hypothesis. There is never, in the scientific method, a final “absolute truth,” only the current theory. I was interviewing an applicant to our medical school who was very twitchy: He could hardly sit still. He made me nervous. I asked him why he was so excited. “Evidence-based medicine,” he said, “at last!” What did he think medical scientists and clinicians did during the centuries before “evidence-based medicine” appeared 22 years ago: divination by examination of the entrails of sacrificial sheep? What is new about “evidence-based medicine” is that it is so analytically exacting in the rigor of its comprehensive critique of multiple clinical studies, that it is now increasingly used to design “critical pathways” and “practice guidelines.” These can be of significant value—but no doctor should think they represent “the truth”: To do that would be like resurrecting Aristotle and Galen. There is a real problem in routinely applying “pathways” to any single person because no unique patient is a cohort, nor just a diagnostic label (e.g., “the diabetic”). Patients often have nonisolatable phenomena at play, unknown and uncontrolled variables. And suffering cannot really be “objectively” observed. A third-year student presenting a woman to me at the bedside said, “She's had subjective pain.” Well, what other kind of pain is there? For a doctor to apply even the best of evidence-based data to an individual without really knowing that person is risky. You must know his or her often complex medical status but must also seek to know, so far as time, urgency of intervention, and the patient allow, as much as you can about them—their social situation, education, beliefs, hopes and doubts, supports, and burdens. To initiate testing or therapies without assessing these things is akin to plating bacteria on an unknown culture medium; it is bad science as well as bad humanity. Today, we live and work in the age of “informatics.” Eighty years ago, the poet T.S. Eliot asked, “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?” Scientific findings are information; knowledge is awareness of what can be done using that information; and wisdom is deciding whether or not to do it. Clinicians, inundated with information in the form of overstuffed electronic medical records, lab and imaging results, medical websites, decision trees, algorithms, screening guidelines, and best practice pathways, have a responsibility to carefully evaluate that information and ask whether it is good, and what can be done with it, and—most importantly—whether it is applicable to our singular patient now. A lawyer once told me that if ever I was the defendant in a malpractice suit by an unhappy patient, and the plaintiff's attorney asked me, under oath, why I did what I did that may have caused a bad result, I had better not answer “I followed the guidelines because I thought I might be sued if I didn't,” but rather “I did it because, knowing this patient, I thought it was the right thing to do at the time.” The scholars and doctors who publish evidence-based guidelines repeatedly emphasize the absolute necessity of crafting them to the unique patient, yet other “assessment-of-care” agencies, both inside and outside of medicine, may not be so wise. Last month, I got a letter from a health insurance company saying that, according to their review of screening guidelines, I appeared derelict in not having gotten annual mammograms for one of my patients. And I did not, I admit, even once recommend mammography to her in any of the seven years following her double mastectomy. Reversals and modifications of guidelines are commonplace: estrogens for all postmenopausal women (Yes!-No!), PSA screening for all men of a certain age (Yes!-No!-Well, maybe), CT scans in the ER for children with head injuries (Yes!-Not always!), breast cancer screening initiation and frequency (Not sure-Arguing now), and many others, including a remarkable percentage of practice protocols endorsing certain medications, tests, and procedures that turned out, in retrospect, to make no difference or did more harm than good. A teacher, when I was a second-year med student, gave me advice for which I will always be in his debt: He was both an academic pharmacologist of international stature as a scientist and a caring physician who would go nights and weekends into the streets and to a drug emergency and ongoing care clinic, which he helped establish, to treat those who were altered by psychedelics, addicted to narcotics and stimulants, or otherwise injured during San Francisco's “Age of Aquarius” in the late 1960s and early 1970s. What he said to me was simple: “Never be among the first or among the last to use a new ‘discovery’.” That good teacher was Dr. Fred Meyers, father of the Vice Dean of our School of Medicine, also Dr. Fred Meyers (here with us on stage today) who is, as an internist and oncologist, a national leader in hospice and palliative care. This “Meyers family history” of compassionate father and son raises a question: Are certain people destined by their genome to be more “humane” than others? Functional neuroimaging of the brain, PET scans, and fMRIs suggest that people make important decisions based not just on data (stored largely in the neocortex) but also on how we feel about those data—value judgments—rising from evolutionarily older (and perhaps inherited functioning) areas—the midbrain and frontotemporal lobes. If it is by feelings that we judge what to do with information, you will need extensive personal contact with patients in vivo, not mainly in silico (a term for computer work my residents taught me), because how they feel about their symptoms, choices, and you as a doctor, and how you feel about their symptoms, choices and them as a patient, significantly affect how each of you uses medical information. Whatever you ultimately choose to do or be in medicine, spend as much time as you can during your postgraduate training with patients, difficult as that is. I say difficult because doctors are increasingly separated from patients by business-based systems designed for rapid throughput and billing rather than for thoughtful hands-on patient care. We are under increasing pressure to “get the work done” in less time to do it than we had before, and the value of “the work” seems to be judged by how extensively, rather than by how pertinently, it is recorded. Many—perhaps most—residents spend more time with computers than they do with patients. We cannot allow the progressive erosion of direct doctor-patient interaction to diminish the role of doctors as, in and of themselves, diagnostic and therapeutic instruments, integrating good science with good understanding of the patient. As the precious time we spend together with them gets less and less, patients may come to be seen as little more than problems to be efficiently solved by following instructions in manuals for maintenance and repairs. And if this happens, medicine will no longer have a proud place among the humanities. You, members of the class of 2014, are the best hope of those who suffer. You are, whether by genome or acquisition—it does not matter—clever and caring people. Now, as physicians, you must repeatedly ask, both of yourselves and of “the systems,” not “Are we getting the work done?” but rather “What is the work?” You will find that answer in the oath that you today are about to take. If you can reclaim and exemplify medicine that is true to that oath, you will receive the greatest rewards that doctors and patients can give to one another: new discoveries and wonderful stories to tell, with rich memories to savor of the enduring bond formed by our shared humanity. I believe you can do this, and so I join in the great pride your families and faculty have in you today. Well done!" @default.
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