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Chinese Medical Journal 2012;125(7):1203-1205 1203

Editorial
Medicine is more than just knowledge or skill
LANG Jing-he

Keywords: medicine; knowledge; skill; humanities

T o say that medicine is not knowledge or skill is


apparently a contradiction. But to say that medicine
is merely knowledge and skill is also off the mark. The
from the same disease. This reality is very different from
that of the natural sciences such as physics, chemistry, or
mathematics; neither can it be mentioned in the same
famous remark by the American physician Edward breath as construction, machinery, nor engineering
Trudeau, “to cure sometimes, to relieve often, to comfort technology.
always,” is the essence of medicine and the embodiment
of medical humanities. Furthermore, doctors and patients have different
perspectives of the same disease. A patient views his or
MEDICINE IS MORE THAN KNOWLEDGE her dysfunction or problem based on his or her own life
experience, whereas a doctor examines a medical
Beyond any doubt, medicine itself is knowledge, which condition according to the medical laws, which are not
can be obtained from a variety of information sources or always consistent with the patient’s thinking. For a
the mass media. But as a discipline, medicine must be doctor, reading, learning, discovering, and even proving
acquired through formal and systematic education. One knowledge is, in fact, based on careful observation and
can only become an independent physician after years of emotional exchange with another life. If there are no
clinical practice. It usually takes 10 years for a graduate emotional factors such as compassion, mercy, love, or
to become a mature surgeon, according to a finding from salvation, the value of medical knowledge is nothing!
a UK survey,1 which coincides with the Chinese saying,
“10 years to make a sword”. MEDICINE IS MORE THAN A SKILL

Knowledge of medicine held by either physicians or Medicine, especially clinical medicine, is of course a
laymen is concept-based, but medicine itself cannot be skill, a highly specialized and complex one. The rapid
confined to concepts; it is based on a combination of development of other sciences and technologies has
image and concepts. Knowledge as information may be greatly promoted the progress of medical technology,
enough for the laymen, but is quite inadequate for even changed medical thinking, routes, and methods. At
physicians. Unlike other occupations that can be acquired the same time scientific advancements increases the
by self-study, one cannot become a physician by merely efficacy of diagnosis and treatment, but it also obscures
going through medical preparatory courses, basic and the disease picture, treatment scheme, or even the goal of
clinical medical courses, or by acquiring the bachelor’s, medicine – to treat an individual patient.
master’s, or even the doctorate degree. In fact, the 5-year
residency after graduation is actually the medical A review of the development in Western medicine reveals
apprenticeship. A resident learns from his or her “master” that a hundred years ago the focus of medicine was to
(consulting physician) how to treat patients. The main understand the human body.2 Over the last hundred years,
task is to validate his or her knowledge and convert it into breakthroughs in the field of medicine have improved our
clinical skills, which in essence is training and practice. understanding of disease and have brought about progress
This process cannot be bypassed or curtailed, no matter in diagnosis and treatment, thanks to the advancements in
how smart one is. One must know that the textbook other sciences as well. In addition to basic medical
description of symptoms is usually “the most typical”, but sciences such as genetics and molecular biology, medical
in clinical practice it is “the least typical”. applications of electronics, optics, instrumentation,
engineering, and computers have greatly changed the
Another feature of medicine is its humanistic nature. The outlook of medicine. The advantages brought about by
subject of medicine is the human being, who has science are clearly encouraging. On the other hand, it
thoughts, feelings, consciousness and will, and living becomes worrisome when clinicians become pure
within a family and society. Every human being has
different physiological and psychological characteristics. DOI: 10.3760/cma.j.issn.0366-6999.2012.07.001
Individual differences are so large that “sit by number” Department of Obstetrics and Gynecology, Peking Union Medical
knowledge oftentimes “cannot find the seat”. There are a College Hospital, Beijing 100730, China (Lang JH) (Email:
hundred manifestations in a hundred people suffering langjh@hotmail.com)
1204 Chin Med J 2012;125(7):1203-1205

scientists. body. The former operates through genealogical vertical


analysis and the latter through network horizontal
First, the purpose of laboratory studies and examinations analysis. Both emphasize internal as well as external
is to look for evidence, but one should not mistake factors, and they interact with each other providing basic
evidence for a medical decision which requires the guidelines for clinical medicine. Thus, we must establish
consideration of other factors as well. When making a medical methodology that integrates holistic
decisions, one must balance evidence, resources, and understanding with dialectical reasoning. Based on this
values. Rational decisions should be made based on system, we should design a “decision tree” for each
actual situations, considering society, economics, and patient, instead of picking up a leaf to judge if “it is
ethics-related humanistic factors. Second, it is not rare to autumn.”
misuse or abuse new technologies. Imperfect skills,
inadequate knowledge, or misunderstanding of the new Research bias
technology will further diminish its value or even cause The significance of medical research is self-evident. If
harm. Third, non-medical factors distort the use of clinical medicine is the body, research and teaching are
technology. These factors are not normal or necessary the wings, without which we can not fly afar. In medical
economic considerations in medical activities, but colleges, we should train not only clinical experts but also
unethical considerations of benefit. Under no therapists who must excel in medical care, teaching, and
circumstances should a doctor be a life-saving angel as research all at the same time. Researches in hospitals can
well as a black-hearted businessman. be grouped into three categories: clinical research,
clinical and basic research, and basic research. None of
At this point, we should really return to the nature and them can be separated from clinical practice.
object of medicine. Back in the 1970s, Dr. LIN Qiao-zhi
revisited the United States. Her main feeling was, Admittedly, we do not look down on basic research.
“Medical technology is very advanced there, but I am Instead, we encourage transformation from
worried that these instruments may become barriers bench-to-bedside and vice visa, to eliminate barriers and
between doctors and patients.” How deep was this promote cooperation to advance the development of
insight! This is a genuine doctor’s philosophy. As a result, medicine. Recently, the trend of translational medicine
she warned us, “A doctor must always come to a patient’s appears to be specialized, centered, and localized,
bedside to do face-to-face work. It is dangerous for forming new initiatives of medical development in the
doctors to rely only on lab reports”. Dr. Higginson3 from new century, and new measures in health care reforms.
the United States also said, “Only at the bedside can But care should be taken to focus on the practicality, and
dignity be rediscovered, by either the patient or the to fill in the so-called “transformation gaps.” Attention
doctor”. If lab reports and flashy equipment are the only should also be paid to “therapeutic misconception,” i.e.,
way to convey information, doctors’ minds will “harden” the mistaken belief that research or experimental results
and “become desertified”, and patients will be “lonely” can be directly applied to clinical practice. Psychological
and “confused”. The questions of “Who is my doctor?” expectations, information temptation, and media
and “Who is my patient?” are likely to blur for both promotion are quick to confuse research findings with
parties. What a worrisome scene would it be if this clinical applications.
happens!
Over-diagnosis and over-treatment
MISPERCEPTIONS AND COUNTERMEASURES Perhaps because of over-emphasis on equipment and lab
IN MEDICAL RESEARCH AND CLINICAL reports, clinical over-diagnosis and over-treatment are
MEDICINE common phenomena. For example, the pursuit of
expensive, multi-item lab tests; abuse of antibiotics; blind
If we merely consider the practice of medicine or medical introduction of new medication and methods, etc., all
treatment as a kind of knowledge and skill, we will be present with temptations to rely on technology rather than
disoriented and confused in medical research and careful observation of the patient.
practice. The following represent the greatest dangers to
the proper practice of medicine. These excesses have at least the following harms: (1)
over-diagnosis gives rise to psychological burden and fear
Lack of overall concept and systematic understanding in the patient, leading to the phenomenon that “doctors
The human body is a dynamic integration and interaction sometimes make the disease”; (2) over-diagnosis can
of organs. The functional coordination and inter-influence cause chaos in treatment, which may delay the true
of organs and systems make it impossible for the diagnosis and treatment; (3) bodily injury caused by
existence of “one organ, one disease”. Today, the over-treatment, or a case of “too much is as bad as too
extensive divisions between disciplines contribute to the little”; and lastly, (4) waste of medical resources. This
deep understanding of each, but also separate them from waste is actually huge, estimated to be one-third or higher
the other. For example, genetics and immunology are of the total cost, or the so-called “the loss outweighs the
fundamental clinical disciplines that consider the whole gain”.
Chinese Medical Journal 2012;125(7):1203-1205 1205

Medicine is wonderful in that many of its aspects are Medical practice is a process in which every gesture and
unexplainable. We must fill the gap between what we action of a doctor reflects the internal character, more
know – our knowledge, experience, and skills – and the than technology. Seeking medical advice is also a
problems we need to solve. At the same time, we need to process, where at all times patients care about internal
seek out answers to medical problems, we should feelings more than results.
consider patients even more, focusing on their quality of
life, and paying attention to the value of medicine. Another basic medical activity, clinical diagnosis and
“Value” here refers not just to the prolongation of treatment, is primarily a philosophical action and ethics:
patients’ survival but also to the improvement in their namely, the aforementioned philosophical reasoning and
quality of life, as well as social benefits of medical decision-making. Professional training and technical
interventions and macro health policy. Treatment does not learning are important without doubt, but a humane spirit
always mean curing a disease, but includes compassion and philosophical outlook are fundamental and lifelong.
and relief of pain. We have to know that moral merit is a kind of intelligence
also. Misunderstanding or lack of ethics may lead to
The alienation between technological advancement and technical weakness or mistakes. We tend to close down
humanitarianism once we are on the track of knowledge. If we surrender to
As early as 100 years ago, Sir. William Osler4 pointed out temptation to do so, then how can we enjoy the intense
sharply the drawbacks of medical practice: lack of beauty of the blending of science and art? How can we
historical insight, a break between science and the obtain wisdom from their mutual encouragement? Only
humanities, and the alienation between technological when we practice from the essence of medicine can we
progress and humanitarian compassion. These three really enhance our professional insight, wisdom, and
problems, now intensified, continue to hinder the spirit.
development and reform of modern medicine and health
care. REFERENCES

In conclusion, medicine is not a pure or perfect science. 1. Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg
On the contrary, it is a system of knowledge, technology, 2000; 87: 28-37.
and awareness that is elusive and constantly changing. Its 2. Porter R. The Cambridge history of medicine. Cambridge:
object is the health of a living organism, a human being Cambridge University Press; 2006.
with thoughts, feelings, consciousness, will, and family 3. Higginson IJ. Rediscovering dignity at the bedside. BMJ
and social context. 2007; 335: 167-168.
4. Osler W. A way of life. Charleston: BiblioLife; 2009.
Also, doctors and patients differ in their experience,
feelings, and ways of thinking. As we try to come up with
core medical values and healthcare rules, we should first (Received August 24, 2011)
keep in mind that “patients are the most important!” Edited by CHEN Li-min