Book Review

The Uncertain Art: Thoughts on a Life in Medicine

N Engl J Med 2008; 359:213-214July 10, 2008

Article

The Uncertain Art: Thoughts on a Life in Medicine
By Sherwin B. Nuland. 198 pp. New York, Random House, 2008. $25. ISBN: 978-1-4000-6478-6

The relentless “scientification” of medical training during the past century has laudably taken medicine far from its roots in hucksterism. Each generation of physicians is steeped in an ever-expanding universe of medical facts. Evidence-based medicine, randomized, controlled trials, clinical prediction rules, and treatment algorithms reassure today's medical trainees that physicians have indeed evolved from shamans and that we are purveyors of science, just like our colleagues who do bench research. In fact, the hallmark of newly minted doctors fresh out of residency training is confidence — not just in their own abilities, but in medicine itself. But as surely as the first bill for malpractice insurance lands on the desk, so too does the awkward lesson of clinical medicine — that the scientific certainty dished out by the medical establishment represents only a small portion of what clinical practice actually is.

It is this uncomfortable lesson that Sherwin Nuland attempts to explicate in his latest book, The Uncertain Art. Having had an active clinical practice for a half-century, he is able to cast a long view over the field of medicine. After paying his dues at the bedside and in the operating theater, Nuland has the credibility, the thoughtfulness, and the time to step back and think about what we physicians do daily — sometimes by rote. Perhaps it is because we do things by rote, or maybe it is simply because we are so pressed for time, that we rarely stop to consider what we know and what we don't know. And we almost never ponder how certain or uncertain our knowledge is — a consideration that is not only time-consuming but also relentlessly unsettling. “The single certainty is uncertainty,” Nuland reminds us. “Only the reliability of unreliability is to be relied upon.”

Sherwin Nuland in His Home Study in Hamden, CT, 1996.

In the introduction to his book, Nuland reports that he is attempting to “stake out a territory whose boundaries are sufficiently vague that I may feel free to roam wherever inclination leads me.” And roam he does. Reading Nuland's book is like sitting on a park bench with an avuncular storyteller of the Renaissance type who cheerfully pulls one anecdote after another from his pocket, each story linked to the next only because he finds it interesting and knows something about it — and he hopes, of course, that you find the stories interesting, too. The chapters in this book are a series of essays that Nuland wrote for the American Scholar, the august journal that was then in the editorial hands of Anne Fadiman. As a collection of essays that were written separately, the book lacks the cohesive spine of a larger, more focused work of nonfiction. But if you relax, lean back on that park bench, and free yourself to roam with your storyteller, there is no telling what you might stumble upon.

I was fascinated to learn that the major critique of Henry Gray's now classic textbook of anatomy (Gray's Anatomy) came in the form of a book review published in none other than the New England Journal of Medicine (known at the time as the Boston Medical and Surgical Journal). The review took up half the pages of the Journal in two successive issues. The reviewer, who signed his name only as H, railed against the major heresy of the book, which was that it employed illustrations — and labeled ones at that. Such diagrams, he argued, would be “use[d] . . . at the expense of the text.” Thankfully, the review carried little weight; otherwise, today's students might still be learning anatomy in the form of prose.

But beyond providing intriguing and amusing facts, Nuland probes a number of complex — and yes, uncertain — topics that are extremely relevant to modern medicine. In the chapter titled “The Medical School and the University,” he writes about the importance of the Flexner report of 1910 that standardized medical education and led to the closure of dubious “proprietary” medical schools. Medical schools affiliated themselves with universities to meet the scientific criteria set out in the report. Although this move had the salutary effect of improving medical teaching, Nuland notes the corollary, that “the leaders of American medicine . . . made an irrevocable decision: the educational institution was also to be a research institution.” Most of us take this for granted, assuming that this is just the way things are and the way they ought to be. But Nuland raises an important point — that the aims, styles, and personalities of education and research can be quite different, and not always synergistic. Just take a look around a medical school and see who has tenure.

A thoughtful chapter titled “The Man or the Moment?” probes the sometimes messy issue of whether scientific discoveries are unique to the “discoverer” or inherent to the times. Reminding us that humanity is inextricably linked to the scientific method, Nuland gives the example of Ignaz Semmelweis (about whom Nuland has also written a full-length book), who demonstrated that puerperal fever could be prevented if medical staff washed their hands in chlorinated lime solution. But his pugnacious personality prevented his theory from taking hold in 1840. The practice of antisepsis did not begin to take slow root until decades later, when it was championed by the mild-mannered Joseph Lister. The number of preventable deaths that occurred in the interim is astronomical. It is quite humbling to realize that these deaths are partially attributable to quirks of personality.

The most moving chapter is the final one, dryly titled “Letters from a Heart Transplant Candidate.” It is the only essay that is not from the series in the American Scholar, and it is the most directly human. In 1987, while preparing to write an article for the New Yorker on organ transplantation, Nuland was introduced to George Leyden, a 56-year-old man with a dilated cardiomyopathy who was waiting for a heart transplant. Nuland casually suggested that Leyden “free-associate” at the computer and then send Nuland periodic updates on his condition. Leyden was an IBM executive, not a writer, but his epistolary outpouring is riveting. Nuland deftly intersperses Leyden's writings with his own observations. We are brought from the outer edges of observation into the depths of the lives of real patients, and it is here that we experience the uncertain art at its most disquieting. The philosophical agony of knowing that the saving of his own life will occur only at the demise of another's is vividly described by Leyden, as are the corrosive effects of waiting. “If mental agony can create a better man,” Leyden writes, “it won't be long before I'm one terrific guy.” We, like Nuland, are crushed when Leyden dies, still on the waiting list. It is here that the uncertainties of medicine enrage us.

It may not be possible to absorb all the stories in this book in one sitting at the park bench. But it is a treat to be able to return frequently to that bench, taking time out from the latest mandate from the Joint Commission that your hospital is scurrying to fulfill to listen to an experienced raconteur spin out another tale.

Danielle Ofri, M.D., Ph.D.
New York University School of Medicine, New York, NY 10016

Citing Articles (1)

Citing Articles

1. 1

   Ira D. Glick, Richard J. Balon, Jacob Ballon, Deborah Rovine. (2009) Teaching Pearls from the Lost Art of Psychopharmacology. Journal of Psychiatric Practice 15:5, 423-426
   CrossRef