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.

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