The Youngest Scientist: Notes of a Medicine Watcher

THE OPEN MIND
Host: Richard D. Heffner
Guest: Lewis Thomas
Title: “The Youngest Scientist: Notes of a Medicine Watcher”
VTR: 1/26/83
Air: 3/26/83

I’m Richard Heffner, your host on THE OPEN MIND. There is a certain joy I feel, a reward, I’ll consider it, for all these years of probing with what I always hope is an open mind, a joy provided by an association with greatness of spirit, of intellect. And occasionally I’m blessed with the opportunity to probe even a bit more deeply than usual into the thinking of a delightful character such as my guest today, Dr. Lewis Thomas, Chancellor of the Memorial Sloan Kettering Cancer Center. Formerly Dean of the Medical Schools at both Yale and New York Universities, Dr. Thomas is not only one of this nation’s most highly regarded medical scientists, he’s also a supremely gracious writer. His essays and books are such a source of delight for all those who embrace the life of the mind. His Lives of the Cell and The Medusa and the Snail prepared us, of course, for the pleasures now of The Youngest Science, his new Viking Press volume subtitled “Notes of a Medicine Watcher”. And I’d like to share these autobiographical notes with you today, this memoir of a dedicated physician. Next time I’ll talk with Dr. Thomas about his views on genetic manipulation and doctors and scientists playing God. And in a third program, I want to probe very deeply his concerns for future life on our nuclear planet.

Dr. Thomas, think you for joining me today. I enjoyed so much The Youngest Science, and I do want to share it with the people who are watching us today. And maybe the best way to do it is by referring to the fact that you talk about a very touching event that illumines the presence in the past on the life and the dedication of let’s say the general practitioner, people like your father. And then after telling this little story you say, “This was in the early 1950s, when medicine was turning into a science, but the old art was still in place”. Well, setting aside nostalgia to the extent that we can, would you trade the old art for the new science?

THOMAS: Oh, no. What I would like to do is have the best of both worlds, and have the practice of medicine continue to be, as it’s always been, a kind of combination of art and magic, and at the same time have it be the science that it’s now showing signs of becoming. I’d hate to give up what is what I remember from watching my father practicing general medicine 60 years ago when I was a small child. And indeed I’m reassured from time to time that colleagues much younger than I am now practicing medicine to indeed use what I call the art of medicine.

HEFFNER: You say “colleagues”, meaning some colleagues, some you can identify. By and large though it seemed to me that that quotation indicated a feeling on your part that there is something in the bygone days about that notion.

THOMAS: There’s a difficulty of having turned into a science with a high degree of precision and with instruments that are capable of making diagnoses and therapeutic agents that are capable of changing disease in ways that we couldn’t have dreamt of just 30 or 40 years ago, a doctor’s life is transformed. He’s much busier. He’s much more, he has to rely much more heavily on technology than ever before. He has less time; the busy ones do, to talk to his patients, to listen to them. It’s a very difficult profession to practice. But the real good ones and the ones that I know who do general medicine even in towns as busy as Manhattan, still do a good job of the art. They are reassuring, they care about their patients, they know the families. They may not necessarily know the name of the family dog as my father did in the time that I grew up in, but they’re good doctors. It’s harder now though.

HEFFNER: You know, in reading The Youngest Science I had the feeling that you were saying that in the past, medicine was a matter of, well, basically of observation; that today we’re much more capable of doing more about what doctors observe. Is that a fair characterization?

THOMAS: Oh, sure. My father began practice around 1905 or 6, and practiced until almost the time of his death in the late 1940s. And throughout most of that time, although he made a lot of housecalls, got up at night and went off to see patients carrying a black medical bag that had a few odds and ends in it, he was never convinced that what he did at the bedside or in the home really made a difference technologically anyway. There weren’t any medicines anemia and insulin for diabetes, a few others, digitalis. But mostly what doctors did in all those years was to use what they had in the way of common sense and a certain amount of science that had been inherited from the nineteenth century in the study of the natural history of disease in order to make a good diagnosis. My father felt that his job was to make an accurate diagnosis and then be able to tell the patient and the patient’s family how it was going to turn out, and then to stand by and give whatever support he could give. And when I went to Harvard Medical School in the 1930s I was taught exactly that kind of medicine. We had a little book we carried around with us on the boards. It would fit into one’s jacket pocket. It was called Useful Drugs. It was about 80 pages long, as I recall. It had, oh, some things about cathartics and opium and aspirin, odds and ends like that. It was very rarely opened. And our instructors at the medical school told us quite plainly that our job was to make a diagnosis, make a prognosis, give support and care, see to it that the patient got good nursing care, and not to meddle. And meddling was the, or the getting away from meddling was the great accomplishment of early twentieth century medicine. If you got sick in the early nineteenth century and fell into the hands of a doctor you had a pretty good chance of dying from therapy. And that was abandoned around the time of Sir William Mosler, and medicine became very conservative. It was even called nihilistic for the first third of the twentieth century. And then, to everybody’s astonishment came the sulfonamides, and then penicillin, and then all the antibiotics, and medicine was off and running and hasn’t stopped since.

HEFFNER: You mean then you could do something…

THOMAS: You could do something, yes.

HEFFNER: …instead of letting nature take its course.

THOMAS: It was a flabbergasting experience. It was as though suddenly in the late 1930s and 1940s those of us who had been trained in medicine discovered ourselves to be doing an entirely different kind of profession, that we could prevent disease – some, not much – but we could certainly cure disease. And that had never before been possible.

HEFFNER: It wouldn’t have been possible without the…Well, I make that as a statement, and I shouldn’t. But I would assume that it wouldn’t have been possible without to some extent the loss of personality that you really deplore.

THOMAS: No, I don’t think so. Oh, no. I don’t think so at all.

HEFFNER: You think the two can go hand in hand?

THOMAS: The two have to go hand in hand.

HEFFNER: Where is it written, Dr. Thomas? I know it’s written in the book, but where else is it written?

THOMAS: Oh, it’s written in much better fashion than in that book in a whole series of essays by William Mosler himself. Now, if we look back into the mostly technical medicine published in the 1920s and republished year after year throughout the 1930s, you find him saying over and over again that the presence of the physician and his reassuring presence, his moral support, is really important in the progress of an illness. There was evidence for that. I’m not sure we pay as much attention to that phenomenon now as we used to, but I’m certainly convinced that if there’s a good doctor at the bedside and if he takes responsibility for the care of the patient there’s a lot more than technology that goes into the patient’s recovery.

HEFFNER: Well, as a layperson, obviously I wouldn’t and couldn’t and shouldn’t disagree with that. But as a former historian, I believe it was John C. Calhoun who in a famous speech in the mid-nineteenth century said cries of, “Health, health!” wouldn’t bring about health, wouldn’t bring about the cures of illness of a patient, and that cries of what ought to be, that hand-in-hand concern for the individual and concern for scientific developments in medicine, that they should go hand in hand, cries for that, how valid are they, how realistic are they when there is so much for, scientifically for the young, learning physician to learn, to absorb?

THOMAS: Well, a lot depends, you know, not on the educational experience of a young doctor in medical school or during his house officership, a lot depends on what kind of a man he is or what kind of a woman she is. There are some people who are very, very good at the management of illness because the like other people. They have a kind of in-built affection. Some of these people are middle of their class as far as grades go. I’m afraid some of the, I’m afraid maybe a lot of them are not being admitted to medical schools these days because of the competition for admission based so heavily as it is on grade achievement. But still there are some. They are very good doctors, and they learn during medical school and during their residency period how to handle the technology of medicine. And they already know because they were brought up that way or they’ve got that character, how to deal with patients with caring and with affection.

HEFFNER: But you know, you are the Chancellor of this great institution here in New York that deals with cancer. And I would suspect that that institution, Memorial Sloan Kettering, puts its emphasis to a very great extent, on, shall I say, medicine by the book, science by the book; and that of necessity a concern for me as an individual or me as individuals must take second place to that rather rigid going by the book of things we do now know. Is that unfair as a characterization?

THOMAS: Well, I don’t know. I think I’m kind of biased in this.

HEFFNER: Sure.

THOMAS: For one thing, I’ve been a patient in my own hospitals, so I’ve seen how it works. My impression is that the high technology that places like Memorial, and this is true for all of the major teaching hospital centers that I know anything about, the patients are regarded and treated as individuals. They know who their doctor is. And they are at the same time provided with whatever the highest technology for cure is that we have. But I get another idea about the hospital, and that is that the people who really hold it together and really make patients feel secure and really know what’s going on from minute to minute, day and night, are the nurses. I have a vast respect for the nursing profession. The nurses and the doctors quarrel sometimes bout the autonomy of the nursing profession. But I’m all for them. I say if I had a lot of power I’d say double all nurses’ salaries overnight and look up to them.

HEFFNER: Well, that certainly comes out in The Youngest Science, because these are the ministering angels, literally.

THOMAS: They’re a good bunch. Great, great ladies.

HEFFNER: Perhaps, Sir, because they’re removed from the necessity of making the same kinds of scientific judgments that…

THOMAS: No, they, in a sense, have an even harder time, Richard. They are…most nurses come into the profession because they like people and like being useful. They want to help. And what they are discovering and have been confronting for the last 25 years or so is more and more in the way of administrative chores, a lot of desk work, a lot of management work, and a lot of technology as well. I think they have an even harder time than doctors because of these two sets of quite unrelated duties that they’re obliged to carry.

HEFFNER: You have an enormous amount of respect for the nursing profession. Again, you’re a very gentle person and you’re not critical in terms of picking on people or groups. Would you agree though, that by and large medical people, trained doctors, people who have gone through, sat in all those seats, done all the work that doctors must do, by and large don’t consider nonmedical people as appropriately ranked with them in terms of their lifesaving capacities?

THOMAS: By and large, by and small. It depends on where you are and what particular population of doctors you’re in close contact with. Those that I’ve known, the young ones coming along as students and residents, I do have a high regard for, I think…I don’t think that as a group, allowing for some exceptions, as a group I don’t find then, the arrogant bunch that they are sometimes called. As a matter of fact, I find a lot of them are having difficulties because they are aware that there are so many things that they don’t know, and there are so many answers that medicine hasn’t yet acquired. There are a lot more diseases that we do not understand at all, we can’t do anything about, than there are diseases that we can manage. And that’s a hard discovery for a young doctor to make. A lot of medical students come into school thinking that medicine is, you k now, just about home and dry, that it’s achieved its mission. And then they confront things like schizophrenia or inoperable, advanced forms of cancer, or rheumatoid arthritis, or the senile dementias. I could make list of 20 or so major illnesses whose cause we don’t understand, whose underlying mechanism we haven’t had a glimpse of yet, and about which we can’t do much of anything.

HEFFNER: You mentioned the senile dementias. And I know from what you’ve written before that this is an area which concerns you greatly.

THOMAS: Yeah, I think it’s getting on to being close to the number-one medical health problem in our kind of society. Primarily because medicine and public health and sanitation, plumbing, and the standard of living in general, better housing, have made all of us healthy enough so that we can live on through the 70s, and in the case of women on the average through their 80s, of not being killed off as we used to be by the big infectious diseases, and to a considerable extent not being killed off by some of the forms of cancer that we are now able to treat. So we’ve got a new population of much older people, and we’re going to have more for the turn of the century, vulnerable to that worst of diseases, senile dementia, where the mind simply shuts down.

HEFFNER: You say, “Simply shuts down”. Are you talking about something inevitable that the machinery just doesn’t work as well and then finally stops working?

THOMAS: No, I don’t think it’s like that. One form of dementia called Alzheimer’s Disease is a real, bona fide disease. It is not just that the organism is wearing down and this is nature taking its course. Indeed, Alzheimer’s Disease can occur in people as young as 50. It’s a devastating disease. It’s due to the actual destruction of neurons in the brain. It isn’t understood clearly at all at the present time. It needs a lot more fundamental research. But it is mot simply something to be put up with because of, as a sort of fact of life, because of aging itself. It’s a bona fide disease that affects people in their advanced years. But I’m sure that it’s a disease which, if we could learn some more about it and really get a clear understand of how it works, we ought to be able to learn how to prevent or cure.

HEFFNER: Dr. Thomas, is it a disease that when you were beginning your Notes of a Medicine Watcher, you were a young man in medical school, a disease that really did exist then?

THOMAS: It existed then, though we didn’t know enough about it and didn’t recognize it. I saw one case of Alzheimer’s Disease when I was junior intern at the Boston City Hospital. And I made the diagnosis before the patient died, and that was the first time, that made my name around the wards for several days, because it was a diagnosis that was only, people thought only could be made at the autopsy table. Now a lot more has been learned about it, and there are, we understand the natural history of it, we know how to recognize it, and also we’re seeing more of it because we’re seeing more older people now.

HEFFNER: And what are we doing about it, if there is anything to be done?

THOMAS: Not much. Really it’s a devastating problem. The nursing home industry tries to cope as best as it can, which is not very well, with it. The state hospitals used to look after patients with the illness, not doing a very good job. And the only answer to it that I can think of is to get on with research on its mechanism as fast as we can. Otherwise we’ll be swamped by simply, among other things, apart from the human misery and the problems it creates for families, it costs an awful lot of money and it will cost, I think the estimates are now that if we don’t find out how it works and how to prevent it or how to cure it. The country will be spending upwards of 50 or 60 billion a year simply for the provision of care for patients with that one disease.

HEFFNER: Moving from that one disease to the area of your own recent involvements at Sloan Kettering Memorial Hospital, what is there in store for the cancer victim, for those of us who are so frightened of the disease?

THOMAS: Well, first off, I think more of us are more frightened of the disease than should be. There are two ways of saying it. One is that 25 percent of us, the general population, will develop cancer before we die. And at the present time with today’s technology half of that group can be saved and the other half not. The other way of looking at it is that 75 percent of us, three-quarters of us, will never get cancer. And most of us who do get it will get it in our advanced years, at the age of 60 or 70 or older. So it’s not really the awful, as it’s sometimes called, epidemic problem that the public sometimes sees it as.

HEFFNER: Why is it perceived as such then?

THOMAS: I don’t know. I sometimes think that the healthier we get, the longer we live, the more anxious we get, we become, about getting sick. We are at some risk of being a hypochondriacal society. We just worry endlessly about illness when in real life most of us are pretty healthy, and when we do get something that goes wrong, most of the time it gets better in the morning. We are not threatened by disease always. And we really are…the human body is an extraordinarily well made invention. Not very many things do go wrong with it considering how many things could go wrong with it. But if you start thinking about how many things can go wrong with it, then you discover, looking in the mirror, that you’re about to come down with something awful.

HEFFNER: We just have about a minute left. Let me ask you about the impact of hypochondriasis. Quiet seriously. It makes us unhappy. Does it do us any real physical damage?

THOMAS: I don’t think so. Maybe it goads us into doing some things that are good for us. I think probably exercise is good for us. I don’t think exercise prevents disease, but I think exercise is per se by itself a good thing to do. It makes you feel better. And I think it induces most of us who smoke to stop smoking. It puts many of us on diets that make us thin and more attractive. It’s got its side benefits.

HEFFNER: You mean a little hypochondriasis will go a long way…

THOMAS: Yeah.

HEFFNER: …and it may not be a bad way?

THOMAS: Just don’t inhale. (Laughter)

HEFFNER: (Laughter) Dr. Lewis Thomas, thank you so much for joining me today on THE OPEN MIND. And we’re going to do these two further programs; one on genetic manipulation and American science, and the other…I know that it’s very close to your heart…one in which we will deal with nuclear holocaust and your feelings about the potential on this planet.

THOMAS: Thanks very much.

HEFFNER: Thank you.

And thanks, too, to you in the audience. I hope that you, too, will join us again here on THE OPEN MIND. Meanwhile, as an old friend used to say, “Good night, and good luck”.