Craftsman

Last night, as my wife and I watched the early minutes of the Republican debate, she commented on how strange it was that Dr. Ben Carson, a physician, could hold such an unscientific view as belief in creationism.

I responded, “A great sculptor does not have to be a geologist, nor does a talented woodcarver have to have studied forestry.”

She felt this was a bit obscure, and requested a further explanation. That explanation took me far beyond Ben Carson.

My point was that a medical doctor, physician or surgeon, is a craftsman, not a scientist. You can certainly turn the proposition around if you like. Finding a great geologist who is also a talented sculptor is also unlikely. Either way works.

The actual “doing” of medicine does not involve scientific methods, but rather the skillful use of tools. For the surgeon, the tools are the familiar instruments of the operating room. For non-surgeons, the vast majority of our proven effective tools are drugs. As time goes by, we medical doctors become fond of our tools, the drugs we use frequently. We get to know them, to feel comfortable with them, and to have a sense of how we can use them most creatively.

How strange, it  seems to me, that we seem to have developed a love-hate relationship with the pharmaceutical industry that provides us these tools. Isn’t it appropriate for the tool-makers to want to share best practices and new information with us? Don’t we want the tool-makers to make improvements so that we have new and better tools to use? And isn’t it reasonable for the tool-makers to want to make a living by charging for the products they make?

The problem is the patient. Unlike the sculptor’s stone or the woodcarver’s log, the patient has a deep sentient and personal involvement in the outcome of the doctor’s craft. In many cases, the patient and/or his agents are also involved in paying for the tools. Now the issue of “value” enters the discussion. Are the tools worth the cost? How do we know? And why advertise the tools to the patients?

In this week’s New England Journal of Medicine, two PhDs from Harvard and Chicago have written an editorial piece titled, “Pharmaceutical policy reform – balancing affordability with incentives for innovation.” They suggest that “our laissez-faire system may not be achieving the balance [between] affordability and incentives for innovation that Americans want.” That’s a difficult point to argue.

In the last few years, the toolmakers have put powerful, effective new tools at our disposal. A “system,” such as it is, that could manage the distribution of sulfa drugs, small molecule anti-hypertensives, and first-generation antibiotics has been overwhelmed by biotechnological synthetics, by monoclonal antibodies, and by novel anti-neoplastic agents. A woodcarver who can handle a good set of chisels, may be somewhat challenged by a 3-D printer.

As I see it, the critical issue for all of us as we struggle toward a new way of making, distributing, and consuming medicine is to maintain our respect for the other participants in the process. The craftsman has to care for his tools and has to have profound respect for his materials. The toolmaker has to feel proud of his role in a creative, life-sustaining activity. And all of us must earn the patient’s trust.

Two Books well worth the time

For any readers who expected a long essay on Chile, this is not it. Instead, as a sort of preamble to Chile, I want to tell you about the two books that served as much of my “airplane reading.”

I found both books, Genentech, The Beginings of Biotech by Sally Smith Hughes and Science Lessons, What the Business of Biotech Taught Me About Management by Gordon Binder and Philip Bashe, as part of my homework for my own non-fiction book on the rise and fall of Scios and Natrecor. They are both university press publications, from the University of Chicago Press and Harvard Business Press, respectively. That, of course, explains why they weren’t on the tables at the front of your local bookstore when you came in to browse.

Does anyone else still do that? My favorite Ann Arbor bookstore is  Nicola’s Books, and I drop in whenever I’m in the neighborhood. Anyway, back to the topic at hand.

The title pretty well explains the subject of Genentech. Hughes does not spare scientific detail, but she writes about it deftly, blending into the narrative. Readers with even the most basic understanding of genetics will hardly notice that they have gotten a short lesson on recombinant technology along with a great story. Some of you may know that Gordon Binder is a former CEO of Amgen; he focuses primarily on the financial growth of the company. Again, the story is so well told that it carries the weight of venture capital financing, cash burn, and initial public offering strategies without a whimper.

With both of these books, I found myself re-experiencing the excitement of my first undergraduate biology course. The Watson-Crick model of DNA was still new science. The whole world of biology had taken on new shape and meaning, and the individuals who started these companies blended science and business in a totally new way.

I loved David McCullough’s The Wright Brothers; these two books capture the same spirit of innovation in a discipline that has been part of our (at least, my) professional life.

Here’s another highly recommended example of outstanding non-fiction writing: Peter Moore’s  The Weather Experiment: The Pioneers Who Sought to See the Future.    

Why is this post on The Weekly Packet devoted to recommending three obscure non-fiction books? (The Wright Brothers is a best-seller; I’m not counting it.)  First, I can’t imagine writing about politics. Second, it’s still too cold to fish. Third, I wanted to slip in just a teeny plug for the nesiritide book because I just finished a second draft.

Stay tuned.

 

Off to the land of giants…

Magellan reportedly named Patagonia as such because of the height (very tall) of the natives. “Patagons” or “giants” by not too literal translation. I’ve always felt that perhaps they just had large feet.  Anyway…

The point is that that the Weekly Packet is going to be pursuing the wily trout in the land of giants for a few days. No thoughtful posting on big problems, small problems, or just ruminations on life. That’s the nice thing about fly fishing. It is a discipline that requires attention to process and detail, and if done correctly results in …sometimes…a fish. Or maybe not.

At any rate, I promise that the next post will include some visuals from “the land of giants.”