Introduction:
a word or two to convince me I know where I’m going,
even when everyone else is passing me going in the other direction.
This is a scientific work. It seems personal and idiosyncratic, no doubt. But my central proposal is that all of clinical endeavor and accomplishment takes place through the personal clinical relationship between patient and clinician. That means the person of the clinician is central, and since mine is the only personality I can make use of immediately it is blatantly exposed in the scientific work I present here. Jose Barchilon used to say all “objective” knowledge has been elaborated since long before we have records, so the only “new” thinking must be “subjective”, personal.
Old and jaded now, I remember when I was young, energetic and opinionated. Like most self-justifying old fogies I think I was right in my perceptions and conceptions, but I see my efforts have accomplished too little. So I have toned down my behavior and speech to a much more humble and private level. I haven’t changed my opinions so much as the intensity of my noise and the thickness of the dust I stir up, my styles of rhetoric which seem always to have put off my well-behaved well-socialized professional colleagues and the institutions they constitute. If only I had been patient enough, I quietly would have waited for the profit motive and power pyramid approach to health care finally to self-destruct. Instead I tired.
I’d give the grand vista and the definitive reform program for health care in the United States, rather than to tell a piddling little story of me and my own experiences and perceptions, but this microscopic view is all I can witness to. Let scholars and historians record and analyze the global long-term picture. If I seem to have puffed, to have pontificated, it is because I am Chicken Little or cursed Cassandra, shaken by the cruelty and the destruction I have seen. I have not merely imagined these phenomena, for we all together have repeatedly re-chosen them and made them real. We have accomplished the usurpation of clinical endeavor for profit and power, against the needs of patients, against the nurturing, teaching and inspiration of clinicians. These violences have been done before--ask Hippocrates my teacher if it was not this way long before he practiced medicine. Ask Michael Shadid or Henry Sigerist how warmly they were not embraced by our establishment and politicians.
My purpose here is not at all political, but purely practical, philosophic, optimistic and clinical. Any political implications, especially those which militate for radical change of our distorted American health establishment, are the direct product of honest clinical thought and action. I try to help us better understand our own perceptions and behaviors in this crucial arena health care, not for the sake of clinical professionals but for the sake of the health of our community.
Clinical responsibility is timeless. It responds to needs we have as patients each and all from our being alive, from our being mortal. Those will not change. My father believed (unknowingly mourning for his dead mama) that technical research and development would eventually defeat the threatening enemy Disease. (How magical and romantic we were in the twentieth century!) Like Hippocrates I try to be rational and practical when I emphasize the relationship between patient and clinician as the center, the fulcrum, the pivot on which diagnosis, prognosis and treatment turn.
It is unimportant to me whether you attend to what I have seen and thought and felt. As living mortal humans you and your loved ones must have benefit of caring skilled attention today and always. Unfortunately for you, your needs of clinical understanding and action severely and increasingly have been abandoned by this society. It is you who must change this. I am convinced the change must be abrupt and radical or it will be no change. It cannot be done gradually, nor can it be done by compromise (which politicians will arduously pursue for the purpose of surreptitiously avoiding any real change). It cannot be based on primitive magical expectations from new gadgets. It cannot depend on romantic heroes in white coats to ride in and triumph over the Enemy. It cannot hide behind the egotistic myth that if I behave well and work hard at it (eating fad foods and running marathons) I will never suffer or die. It cannot rest on the self-righteous conceit that I am so precious I will be preserved despite my self-indulgent self-destructive misbehaviors.
Hippocrates and I think it must pivot on one person caring for another and on those who care teaching each other what they have learned from their patients.
All thought is wordplay. I apologize for bad puns (such as the too-cute subtitles of some of the chapters and the pseudo-mathematical titles of the groupings of chapters) but I hardly invented these sorts of dialogue. Perhaps Aristophanes did that, or Plautus. The essays here are responses the thoughts of which are woven to reflect on questions posed by patients, students, colleagues or clinical situations. It is from the ironic strain of real life that puns rain down upon us. Kind persons have tried to make me talk straight, especially about such serious matters as what happens when we are clinicians, or when we are patients.
I thank the friends who read these for me and with me. The first edition was typed by Roberta Pollack, the same mother who typed my papers in the third grade; she’s still alive, and she is gratified that you are reading this. My friend Bob Jaeger has read and edited this expanded second edition with me, kind enough to do good work gratis, declining to accept even the smallest token for himself. I cry to see such generosity toward me and my life-work. He will appreciate donations from you for the Meher Baba Institute in India (through the Meher Baba Trust www.ambppct.org/trust/where-to-contribute.php), a spiritual center which sustains him and many of his fellows around the world (well-behaved dervishes who whirl only while sitting sedately).
It is tedious to read a list of thanks to teachers. You’ll recognize through this text some whom I lean on, referred to explicitly or implicitly. Mostly, I thank your teachers for bringing you to me. It is not easy to study alone.
I cannot tell you how profoundly I appreciate those who have read this collection of essays to help me make more clear to you the lessons I have learned. I cannot convey how profoundly I appreciate you personally for reading this. If there is anything here that helps you live happier or kinder than you might have otherwise, I have been rewarded.
Good luck to you and to all of us.
Be well.
Nathan Pollack, MD