Doctors being held back from intellectual creativity a disservice to patients

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Ken Fisher, MD, who is an internist/nephrologist in Kalamazoo, Michigan, a teacher, author ("Understanding Healthcare: A Historical Perpsective") and co-founder of Michigan Chapter Free Market Medicine Association. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Dr. FisherFreed from millennia of dogma with the emergence of the scientific method, combined with Enlightenment ideas about the resourcefulness of the individual, there was an explosion of advances in medicine during the 19^th century.

Dr. Edward Jenner (1749-1823) became the father of Modern Immunology and the concept of vaccination with his work with smallpox, a viral disease that was a scourge of mankind for millennia.  It decimated large numbers of never infected individuals especially when congregated into groups.  

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In the eighteenth century, Lady Mary Wortley Montagu returning to Great Britain from Turkey introduced the concept of variolation, the taking of infected smallpox material from a patient and inoculating it into a never infected individual.  Most became immune after having a mild disease; however, some died.  

In spite of its dangers, when faced with a smallpox epidemic among the Continental army in 1777, General Washington used variolation to save his army, but with some casualties.  

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Edward Jenner was aware that occasionally farmers who had cared for horses that had developed an exudate on their hoofs, without washing proceeded to milk cows.  He noticed that the cows developed smallpox, like pustules on their utters.  After milking the same cows, Sarah Nelmes developed an extremely mild case of the “pox.”   Then, in an experiment that could not be done today, he inoculated a young boy James Phipps with material from Sarah’s pustules.  James did not develop “pox” even after being inoculated with actual smallpox material.  Jenner repeated this several times with the same result and published this work in 1798. 

He had no concept of the attenuation of the virus, but used his keen observations to develop the concept of immunization.

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Dr. Rudolf Carl Virchow (1821-1902), father of modern Pathology, debunked the concept of spontaneous generation, proving that all cells originate from precursor cells.  He mastered microscopy while a student at the Prussian Military Academy, studying medicine and chemistry.

 Influenced by the more scientific medicine evolving in Great Britain and France, he believed that clinical observation, microscopic examination of the diseased tissues and animal experimentation were the keys to understanding human disease. 

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Along with another pathologist, Dr. Benno Ernst Heinrich Reinhardt (1819-1852), Virchow founded the eminent pathological journal Virchow Archives. He was the first to describe that frequently accompanying GI malignancy the supraclavicular lymph node on the right became enlarged with trapped cancer cells. 

This is now described as a “Virchow Node,” which, when biopsied, is an efficient diagnostic tool for metastatic adenocarcinoma.  Virchow was also a pioneer in the concepts of thromboembolism and invented the liver temperature probe to help determine the time of death. 

Dr. Virchow studied skull measurements and was vocal in disclaiming the presence of any Aryan superiority.  He was a social activist believing that physicians were in a unique position to understand the plights of the poor and should work to improve their situation.

For at least a century and a half since Virchow, the pathological processes causing death were taught to physicians via the autopsy, thereby significantly improving physicians’ clinical skills.

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 Unfortunately, because of funding issues, autopsies are now far and few between.  There is, among some circles, the idea that autopsies are no longer needed because of advanced radiological techniques.

This is false.

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Surprise findings are just as frequent today as in the past.  The losers in this situation are patients who are being treated by physicians with somewhat less clinical acumen.

Dr. John Snow (1813-1858), known as the father of epidemiology was certainly a multi-talented physician.  In 1853, Dr. Snow, used chloroform to facilitate the birth of prince Leopold, Queen Victoria’s eighth child.   This was seven years after the dentist Dr. William T.G. Morton (1810-1868) with Harvard Professor Dr. John Collins Warren (1778-1856) demonstrated the use of ether as an anesthetic agent for surgery.

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There had been resistance among the clergy for anesthesia during childbirth, but because of the prestige of the Queen, it quickly subsided.

Dr. Snow’s biggest achievement was the discovery, before the germ theory of disease, that sewerage contaminating the water at the Broad Street pump in the Soho district of London was responsible for a frequently fatal diarrhea disease. 

He did this by careful interviews of patients and families determining the water pump as the source and discovering that there was sewerage contamination of the water, publishing his full results in 1854. He thus was the first to describe the fecal-oral spread of disease disproving the contemporary belief of the “miasma – bad air” theory.

This is not a complete story of the major medical advances in the first half of the 19^th century, but rather an example of the explosion of intellectual creativity that began then and needs to be encouraged to this day.