This book consists almost entirely of a series of essays as they appeared in The American Scholar between 1998 and 2004. As
I read through them today, I realize that some of the hopes expressed here are already in the early stages of being fulfilled,
while others are as far from fruition as they were when first proposed. They represent the Art, as Hippocrates called medicine, seen by an ardent admirer and unsparing critic—a man honored to have participated in its daily wonders and
uncertainties for half a century. They tell of the practice of medicine as I have observed it and loved it—and lived it.
The final story has not previously been published. It is written in tribute to a brave man who became my friend during the
final period of his life, a man I respected as I have few others. When certain of the expectations appearing in this book reach
a state of practical usefulness, the day will come when no man, woman, or child will die awaiting the transplantation of a
donor organ. May that day be soon.
There is wisdom in the acceptance of uncertainty. Well used, it can make a philosopher of an ordinary man. To the intuitive
mind of the twenty-two-year-old John Keats, that precious insight appeared in a flash of understanding one day in 1817, while
he was deep in conversation on a long walk with two friends: “[S]everal things dove-tailed in my mind, and at once it struck me what quality went to form a man of achievement,” he later wrote in a letter to his brothers. “I mean negative capability,
that is, when a man is capable of being in uncertainties, mysteries, doubts.” To become comfortable with uncertainty is one of
the primary goals in the training of a physician.
Keats wrote those words—italics and all—during the period when he was composing Endymion. Less than a year earlier, he
had stopped attending the series of lectures that were to prepare him for the examinations of the Royal College of Surgeons.
Although poetry and the pursuit of sunbeams had long since become Keats’s passions, he had been anything but an
indifferent student. The statements of contemporaries attest to his skillful performance of clinical duties, and he had already
qualified to practice medicine in July 1816, following a year’s study at Guy’s Hospital. Medical education was brief in those
days. Although the examinations were difficult, there was little of real usefulness to learn.
It was not possible for a perceptive man to study medicine in the early nineteenth century without becoming aware of the
degree to which patient care was conducted in a pervasive atmosphere of inexactness. Like all young doctors of the time,
Keats very likely admired his teachers at Guy’s all the more for their ability not only to be decisive in the face of uncertainty
but actually to thrive in the absence of clear clinical signposts. Even the basic principles of physical examination were not
well known by most doctors, this being the period when they were originally introduced—and in Paris, no less. It was in 1816,
in fact, that René Laënnec, a Breton who at five feet three inches was almost as diminutive as Keats himself, invented the
stethoscope.
For physicians, the nineteenth century was characterized by the gradual infiltration of new scientific findings into medical
thought. The process accelerated rapidly in the 1880s and 1890s, as the products of laboratory investigations in physiology
and bacteriology were finally shown to be of practical use at the bedside. By the first decade of the twentieth century, an
increasingly credible, scientifically based medicine had routed the forces of homeopathy and the other irregular sects that,
until then, had retained some hope of gaining ascendancy. From that point onward, the Holy Grail would be a form of practice
based on knowledge gained by observation, hypothesis, experiment, and verification, in which uncertainty, if a factor at all,
would be quickly dispersed by the next series of laboratory or epidemiological studies—a discipline, in other words, that might with real justification be called a science.