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| Osler examining a patient |
On the flight back from England to the US I watched the movie “My Week With Marilyn”. It’s a movie that’s based on the true story by Colin Clark
of the time he spent working for Sir Laurence Olivier directing and acting in a
movie featuring Marilyn Monroe. Ms. Monroe was at the height of her fame. One
theme that emerges in the movie is the difference between "method acting" versus
being a "star". Olivier’s career was founded on learning acting through school,
the stage, and finally movies. Olivier was a star also but he started as a "method actor". Monroe had “star power” that captivated millions of movie-goers, but really would never be viewed as a method actor.
As I watched the movie my mind turned to the couple of weeks
I attended on the general medicine service at the Brigham. As the attending
physician I led a team of young doctors – interns and residents as they worked
up and managed patients. The residents that I worked with were terrific. Smart,
knowledgeable, and hungry to learn. I certainly couldn’t best them in
knowledge.
One of the intern's asked me: “what do the years of practice bring?”
Taken aback at first, I told him that experience brings intuition in diagnosis and perhaps more importantly in recognizing the sick patient. It comes from immersing oneself over many years
in the practice of medicine. As I've thought more about it, similar to "method actors" using years of practice on stage in
developing the ability to draw upon their own emotions and experiences, doctors use years of observation and trial and error in
treating patients in developing this thing called "intuition". Osler said: “He who
studies medicine without books sails an uncharted sea, but he who studies
medicine without patients does not go to sea at all.” He goes on:
“There is a tendency among young men about hospitals to study the cases, not
the patients, and in the interest they take in the disease lose sight of the
individual. Strive against this.”
But in addition to developing
intuition, the experienced clinician brings to the table skills learnt by
practice. Take the essence of Malcolm Gladwell‘s book “Outliers” or Atul
Gawande’s “Better” - they both speak of the importance of practice; Gladwell of
over 10,000 hours of practice and Gawande of practice in reducing error rates.
This brings me to an article that first appeared in in the
Summer 2002 issue of the Harvard Medical Alumni Bulletin.
It contains quotes from Harvard alumni the about the “art of doctoring”. The quote
that caught my eye was as follows:
A River Runs Through It
The difficulties of training a man in the art of medicine
remind us of Mark Twain’s description of how he became a Mississippi pilot.
Successful piloting was not merely a matter of twirling the wheel, ringing
bells, and looking important; one had to know the river, not only by day but
also by night and in the fog, and since the river changed continuously one had
to have foreknowledge of every change. Finally by some sort of growth of his
intuition he became a first-class pilot —Medical School Notes [June 1941]
Even in 1941, “some sort of growth of [his] intuition”
seemed important and it’s no less important today. With the constant hand-overs
and shift changes the intuitive ability to figure out who is sick and who isn’t
is even more important than it perhaps was. I have no doubt that knowledge is important and developing habits through practice are key, but I would suggest to you that it's the developing of intuition that seems the overarching benefit that comes from experience. Who would you rather have treat you? Dr.
House “the star” or Dr. Marcus Welby the “method actor”?
