Anthony Papagiannis
Thessaloniki, Greece

 

The ruins of the Asclepeion in the Greek island of Kos, the birthplace of Hippocrates. Photo courtesy of author.

Some five centuries before Christ, the ancient father of medicine Hippocrates used to instruct his students that “Life is short and Art is long; opportunity fleeting, experiment treacherous, judgment difficult.” (Ο βίος βραχύς, η δε τέχνη μακρή, ο δε καιρός οξύς, η δε πείρα σφαλερή, η δε κρίσις χαλεπή). To this translation,¹ I would suggest two linguistic amendments. Instead of “fleeting opportunity” one could talk of “acute” or “urgent circumstances” (καιρός οξύς: both interpretations may be correct), while “treacherous experiment” (πείρα σφαλερή) is more correctly translated as “fallible experience.”

Most medical students are familiar with this first Hippocratic aphorism, which contrasts the shortness of life with the length of the Art of medicine, and highlights the urgency of acute medical conditions, the fallibility of human experience, and the difficulty of making correct judgment on the basis of insufficient data in complex situations. It is worth revisiting some of the provisions of this statement and reflect on their meaning and significance.

By “short life” we usually imply there is a need for lifelong learning and continuous updating of our scientific knowledge. With time, however, we come to realize that no matter how much we learn there remains more to be discovered. Today we know a great deal more than we did as students, but even this enhanced knowledge is a mere drop in the ocean. The late Franz Ingelfinger once wrote that “superior scientists or doctors are always aware of how little they know,” and this awareness should protect them from the “arrogance of ignorance.”²

The ancient sage Thales of Miletus (624-546 BC) used to say that “Time is the wisest of all things that are; for it brings everything to light.” Time does indeed make us wiser, and also more humble in the face of what we do not know. Each day shows us something new: many things are similar and yet different. Variations, deviations from the norm, and atypical presentations of the same condition are all part of the overall experience. This is now an accepted rule in scientific circles. Thus until recently we used to grade chronic obstructive pulmonary disease as mild, moderate, or severe on the basis of spirometric figures alone. Now we talk primarily about disease phenotypes and individual variation, and realize that despite their objectivity numbers do not divulge the whole truth about a given patient.³

Time begets human experience. This has many forms and faces, and includes the realization that “all things human are vain” (Ecclessiastes), that all things pass and are in a state of flux. Even so-called scientific, evidence-based knowledge is under continuous review: many “constants” become debatable, and time-honored axioms are annulled overnight (the shelf-life of knowledge is very short nowadays). For example, the advice given today to patients after a heart attack or peptic ulcer bears no relationship to the strict bed rest and bland diet invariably prescribed a few decades ago. Experience can indeed be fallible. Gradually the physician begins to look upon medicine, health, even life as a whole, more philosophically.

This level of consideration may be reached earlier or later in a doctor’s path. Its development may be shaped by each person’s broader education, overall culture, philosophical perception, and religious or other transcendental faith or belief. It is also affected by the continuous professional contact with patients, and not least from any personal disease or disability. Without such practical experience the philosophical consideration will be incomplete or even void.

Only one or two generations ago most doctors had suffered at least one of the serious maladies of that era, such as tuberculosis, malaria, typhoid, dengue fever, etc., by the time they had graduated. They had first-hand knowledge of pain, shaking chills, fever, exhaustion, or debility before they undertook to relieve other people of their symptoms. This personal experience made them more understanding and compassionate, gave them the precious gift of empathy, and made them better and more humane doctors, even though they had much less science to offer to their patients.

We commonly refer to the science and art of medicine. Science can be said to comprise the sum of existing knowledge, and is based on data often expressed in statistical terms. For example, disease A has a mortality of 10 percent; symptom B is present in 80 percent of cases; treatment C has a cure rate of 50 percent, and so on. These figures help to reduce the uncertainty inherent in incomplete medical knowledge, which is a source of stress for physicians.⁴ However, a patient dying from the disease will not be particularly satisfied with our assertion that his disease is only 10 percent lethal and he just happened to belong to this unfortunate minority: for that patient death will be one hundred percent. Statistics can be pretty cruel.

The Art of medicine can be described as the process of translating existing knowledge and scientific data into a practical approach, and applying it in an appropriate manner to each individual patient. This is expressed by several well-known dictums such as “There are no diseases; there are only patients” or “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has” (William Osler). If all patients were the same, medicine would be reduced to a mere applied science. Art in combination with Experience, as outlined above, could be defined as Wisdom (which stands one step above Knowledge and two steps above Information, as famously stated by T.S. Eliot).⁵

Oscar Wilde wrote that experience is simply the name people give to their mistakes. This describes in a satirical way the “fallible experience” of Hippocrates. In practical terms it means that even if you have seen one thousand patients with a particular disease, the next one may present in a slightly different way and confuse or mislead you. Medical conclusions are almost always the result of incomplete deduction, as opposed to mathematical precision, making judgment difficult. Even the most comprehensive consensus statements or guidelines cannot cover all possible permutations of disease.⁶

Another thing we learn with time is to temper our moral rigidity with mercy and compassion. When we are young the ideal of absolute justice tends to make us rebels: nothing short of just retribution is good enough. Thus patients must suffer for not following medical advice, and doctors ought to be punished for every mistake. As we grow older in the profession we dilute the hemlock of condemnation with the oil of compassion and understanding for our patients, their relatives, our colleagues, and the rest of the world. We realize that we are all subject to the fallibility of experience, and there are no exceptions to this rule: today it is your fault, tomorrow it may be mine. The Golden Rule of human behavior, as stated in the Gospel, “Do unto others as you would have them do unto you,” applies in medicine as well as in every other walk of life. We must not think and act as public prosecutors but as advocates, helpers, and compassionate counsellors, according to the circumstances.

We also learn to accept that our inexact science still has its dark corners; many diseases still elude diagnosis and treatment; many patients do not get well even when we do know the diagnosis and have the means for treatment. This realization should prevent us from making proud promises of perfect results and giving premature assurances when situations are uncertain. In such cases a negative outcome will turn patients and families against us, and at the very least cause serious damage to our credibility. As the saying goes, “Some you win and some you lose.” And, unfortunately, some die, even in the best institutions and under the most advanced and meticulous care.

So what have we gained by our scientific progress? We have learned much, and our experience today is less fallible, our judgments slightly less difficult. But we also know that with all these advances we have barely scratched the surface, and Life is indeed too short for the length of the Art. Two and a half millennia after Hippocrates, his first aphorism has yet to become outdated.

 

References

1. Antoniou GA et al. A contemporary perspective of the first aphorism of Hippocrates. J Vasc Surg 2012; 56 : 866-868. Available at https://www.jvascsurg.org/article/S0741-5214(12)01046-4/fulltext
2. Ingelfinger FJ. Arrogance. N Engl J Med 1980; 303:1507-1511.
3. Baum GL. Reliability coefficient. Man versus machines. Chest 1993; 103: 4-5.
4. McCue JD. The effects of stress on physicians and their medical practice. N Engl J Med 1982; 306: 458-63.
5. Papagiannis A. Eliot’s triad: information, knowledge, and wisdom in medicine. Hektoen International Spring 2014, Vol. 6, Issue 2. https://hekint.org/2017/01/29/eliots-triad-information-knowledge-and-wisdom-in-medicine/
6. Papagiannis A. In a scan, darkly. Hektoen International Summer 2017. https://hekint.org/2017/09/13/in-a-scan-darkly/

 

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ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP, is a practicing pulmonologist in Thessaloniki, Greece. He trained in Internal Medicine in Greece and subsequently in the United Kingdom, and specialized in Pulmonary Medicine. He also holds a postgraduate Diploma in Palliative Medicine from the University of Cardiff, Wales. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, Greece. He also edits the journal of the Thessaloniki Medical Association.

 

Highlighted in Frontispiece Volume 11, Issue 4 – Fall 2019

Spring 2019  |  Sections  |  Doctors, Patients, & Diseases