A Career in Medicine: Do you have what it takes? second edition

Rameen Shakur

• Publisher: CRC Press
• Year: 2006
• ISBN:
  9781444166583
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Have you ever thought about becoming a doctor but weren't sure where to start or what to expect? This book provides a comprehensive resource to guide you through the various stages involved in becoming a doctor, from deciding whether medicine is right for you, to choosing and applying to medical school, interview skills, student finance, plus what

1 Medicine: Remembering the past, looking to the future

Abhishek Joshi, Graduate Entry Medical Student, University of Oxford
Dr Rameen Shakur, F2 Academic Medicine Rotation: Cardiology. Nuffield Department of Medicine, the John Radcliffe Hospital, University of Oxford

Doctors practising today can call on a huge body of knowledge and experience when they treat their patients. There are thousands of journals to read, hundreds of guidelines to follow and an almost unlimited number of scientific ideas to be used. Practising as a doctor involves applying new scientific discoveries and inventions to some old problems.

Yet it was not always like this. Every time a doctor takes a blood sample or listens to a patient’s heart, he or she is utilizing thousands of years of thought, experiment and experience. There have been doctors, or people like them, for thousands of years, but their methods have been evolving and only very recently have they started to use the techniques that we are familiar with. The first doctors knew nothing about cells, organs or drugs. You might very well wonder how they managed to treat people at all, but they did. This chapter explores some of the major historical advances in medicine and those that helped shape the ethos of medical practice.

The spirit of medicine

Much of modern Western medicine stems from the ancient Greeks, where the main practitioners of medicine were priests. The ancient Greeks originally thought that diseases were caused by the gods deciding to punish the patient. The treatment was prayer, and many priests would prescribe patients potions that would make them enter a state of shock. The idea was that a god could then appear before them and they could ask to be made well again. Medicine was closely associated with magic in the very early days, and the Greeks used combinations of ‘magic numbers’ in their treatment of diseases. For example, patients who were ill were quarantined for 40 days, because the number 40 was considered to be magical!

The idea that illness is some sort of punishment from God or the gods, and that it can be cured by prayer and ritual continues today. In fact, some scientists are now engaged in researching whether prayer actually works to improve people’s health.

Hippocrates

After a while, the Greeks began to think differently about the world around them, and also about disease and health. In particular, Hippocrates (460–377BC) introduced a number of new ideas, and is now known as the ‘Father of Medicine’. Hippocrates taught his medical students how to recognize the outward features of disease, and encouraged them to learn which features suggested the severity of the disease. This brought about the idea that doctors could make a diagnosis and a prognosis for a person based on observation, and helped Greek doctors to begin to classify illnesses.

Hippocrates also popularized the idea of the ‘humours’ in medicine. The Greek theory of the humours was that everything in the world was made up from a combination of the four elements: air, water, fire and earth. Hippocrates associated these elements with humours (or fluids) in the body: air with blood, green bile with fire, black bile with earth, and phlegm with water. He believed that if someone had too much of one of these humours, the resulting imbalance, or dyscrasia, caused illness. The obvious cure, then, would be to remove some of the humour, so he suggested sneezing or vomiting as cures for diseases. Interestingly, Hippocrates also believed that doctors should try to do as little as possible and let the patient recover naturally.

These theories of humours are ‘holistic’, in that they treat the energies of the person rather than the specific disease, but people like Hippocrates did begin to recognize the importance of individual organs in the body, suggesting that they had a role in producing the different humours. Hippocrates was also credited with writing the Hippocratic oath, the ethical code of conduct that doctors swear to follow, although a number of similar oaths existed before his time. Interestingly, the Hippocratic oath separates doctors from surgeons, as surgeons were considered uneducated servants of the doctors.

Ayurvedic medicine

The idea that illness was characterized by an imbalance in the patients’ elements was not exclusive to the Greeks.

Early Indians practised the Ayurvedic method of medicine over 3000 years ago, and the practice still survives in India today, often allied to modern ‘biomedical’ practice.

The system teaches doctors to maintain a balance between the five elements of ether, air, water, fire and earth. Early Hindus believed that the knowledge of Ayurvedic medicine came directly from the god Brahma, and the main texts were the Charaka and the Sushrata, which were written down after a period of word-of-mouth. The system is very complex, and divides the mind, body and soul into separate systems. There are detailed explanations of how disease occurs and specific medicines for each disease, aimed at restoring the patient’s balance. Ayurvedic physicians had to learn eight different disciplines: internal medicine; surgery and anatomy; eye, ear, nose and throat diseases; paediatrics (and embryology); demonology (or psychiatry); toxicology; rejuvenation; and fertility.

In addition, the physician would have to master the study of chemistry, so he could make his own medicines, which were usually made from plants. Training took seven years, and at the end doctors were required to take an oath promising to put their patient’s care above all else.

The Egyptians

Hippocrates’ teaching remained popular in ancient Greece, and was refined over generations. As Alexander the Great spread his influence across the Mediterranean, his scholars took the Hippocratic model with them. When the great library of Alexandria was founded in Egypt, the Greek methods met with the (much older) Egyptian doctrines. This meeting was particularly fruitful.

The Egyptian method of practising medicine dates back to 3000BC. The Egyptians, too, believed that illness was due to the influence of gods and spirits, and they used an array of potions and spells to heal their patients. The Egyptians worshipped one of the first royal physicians, Imhotep, as the god of healing. Imhotep wrote what has become known as the ‘Edwin Smith Papyrus’. This documents, in exquisite detail, the Egyptian methods for examination, diagnosis, treatment and prognosis of a number of diseases. The Egyptians were also aware of public health, and by 1150BC (the 19th Dynasty), they were providing medical insurance and sick leave for workers building the pyramids.

The crucial difference between the Greeks and the Egyptians was in their study of anatomy. Whereas the Greeks considered the body sacred and so did not dissect cadavers, the Egyptians dissected cadavers as a matter of course. This led to a better understanding of human anatomy. The Egyptian understanding allowed surgical practice to develop, and the Egyptians also had a better understanding of things such as the pulse and the functions of different organs.

Some scholars at the school in Alexandria attempted to use an empirical approach to medicine. This meant that they listened to the patient’s complaint (a history), examined the patient and then made a diagnosis – just as doctors do today.

The problem was that these doctors did not understand the diseases they were studying well enough to relate the symptoms and signs to a disease, and when they could, they did not know what to do about it. This meant that the perfectly rational idea was out-competed by the ‘methodic’ school, who were obsessed with the state of patients’ pores. This school of doctors thought that the pores on the skin were a direct reflection of the patient’s health, and so they suggested a number of ways in which a person should wash in order to maintain healthy, open pores. The theory was popular because doctors could see the direct results of their treatments, even if they did not actually cure any diseases.

The Romans

As the Roman Empire began to take its hold in the 1st century AD and the Greeks became poorer, many Greek doctors continued to ply their trade as Roman slaves. Being a doctor in Rome was seen as a socially undesirable job. However, a number of doctors were successful and were able to buy their freedom. One of the most successful Roman doctors was Galen (AD129–200), who was the son of a wealthy architect. He was never a slave, but instead studied at Alexandria, where he learned the Hippocratic theories of medicine, which he then brought to Rome. He developed these ideas and furthered the study of anatomy through public dissections of pigs and Barbary apes, which he considered to be anatomically similar to humans. He showed that the kidneys produced urine and demonstrated the importance of the spinal cord, but despite these useful experimental findings, Galen’s effect on medicine was effectively to halt any real progress for over a thousand years after his death.

Galen recognized the importance of blood in sustaining the body, but thought that it was produced by the liver and then consumed by the rest of the body. He thought that blood was given a ‘natural spirit’ in the liver, a ‘vital spirit’ in the heart and an ‘animal spirit’ in the brain. Blood was then supposed to travel through the nerves to nourish the rest of the body with its spirits. The theory’s flaw was not so much that it was inaccurate, as that it unfortunately fitted so well with the Christian ideas of the time. This meant that Galen’s theories were promoted and protected by the Church in Europe, which ensured that his anatomical findings and theory of medicine were not challenged for over a thousand years. For example, people believed that the humerus bone in the arm was curved because Galen said so, and dismissed the straight bones they saw as ‘tricks of nature’.

Galen’s teachings thus survived virtually unchanged well into the 17th century. The main change over this time was the introduction of patron saints for each disease. These saints were petitioned for cures, in a return to the earlier ideas and superstitions that God or spirits intervened in man’s health. For example, St Fiacre was supposed to protect the patient from haemorrhoids. There were few practical advances – medicine had entered the Dark Ages in Europe.

The Middle East

While European medicine had come to a virtual standstill, the Arabic world began to flourish. In the 6th century AD, King Khusraw of Persia began to welcome Christian refugees from the Byzantine Empire in the West and scholars from India and China in the East to Gondeshapur (in modern-day Iran). There they translated their texts and shared their accumulated knowledge, founding the first medical school. This cross-pollination of medical cultures allowed students in Gondeshapur to combine the different strands of medicine and to develop their ideas further, which provided fertile ground for the development of a number of eminent Middle Eastern medics.

Al-Razi (865–925) and Ibn Sina (Avicenna) (980–1037) were two major Arabic physicians, who wrote over 600 books between them. They both studied medicine alongside philosophy, mathematics, and other sciences and arts, and are credited with keeping the tradition of rational thought and discovery in medicine alive. Most of their work found its way to Europe, where it formed the basis of medical teaching.

Al-Razi lived in what is now Tehran in Iran. Despite being strongly influenced by the Hippocratic way of thinking, he described the symptoms and signs of diseases and did not try to explain them in terms of spirits or humours. He wrote about the diseases of smallpox and measles, and was careful to mark the differences between them. He relied on rational thought and observation, and this helped him make his discoveries. He also began to publish the first doubts about some of Galen’s teachings.

Ibn Sina qualified as a doctor by the age of 18, and came to live in Tehran as the court doctor to the emir (king). He wrote almost constantly, and consolidated everything he knew about medicine (which in those days was considered to be everything there was to know about medicine) into a 14-volume book called Canon of Medicine. Ibn Sina built on the teachings of Galen and Al-Razi, and added his own experiences to his work. His book describes many diseases and what he thought caused them. He also described the functions of the various organs. In addition, he suggested that tuberculosis is infectious (something that European scholars disagreed with) and gave a clear account of the symptoms and complications of diabetes. The Canon was translated and distributed around Europe, and became the standard medical textbook for the next 700 years.

The Renaissance

Although progress in Europe was much slower compared with the golden era of the Middle East, this does not mean that nothing was happening in the field of medicine. The study of anatomy was progressing, not due to the work of doctors, but because of the work of artists such as Leonardo da Vinci (1452–1519). Da Vinci was interested in the human form from an artistic viewpoint, but soon began to study anatomy in a more systematic way. He was allowed to dissect corpses in the hospitals of Florence, Rome and Milan, despite the disapproval of the Church. These dissections led to some of the first accurate representations of human anatomy in Europe. Da Vinci described the skeleton, the skull, the positions of the organs and the attachments of the muscles. He discovered that the heart had four chambers, and had planned to publish all of his anatomical drawings, but died before he could do so.

Also working in Renaissance Italy, Vesalius (1514–1564) picked up where da Vinci left off. He was the first physician to base his anatomical knowledge directly on his dissection work – a huge break from the prevailing tradition. Up to that point, the study of anatomy in medical circles had come from Galen’s work and from philosophical discussion. Vesalius demonstrated that the internal organization of the body was the same in all people, and that the organs were real, solid objects and not just theoretical concepts. He introduced the idea to medicine that ‘seeing is believing’ into medicine. Unless he could prove something by looking at it, he did not believe it. He contributed much to the study of anatomy through publishing many of his drawings and studies, but his main contribution was to start to change the way in which physicians thought about their subject. Doctors were no longer supposed just to accept previous dogma: they were encouraged to investigate and experiment and to base their practice on objective, observed measurements. Medicine had ceased to be an art, and was becoming a science. The application of rational thought and experimentation, along with the encouraging new political atmosphere, allowed the birth of science during the Renaissance. A better understanding of anatomy gave clinical techniques such as percussion and ausc...

Table of contents

• Cover
• Title Page
• Copyright
• Contributors
• About the editor
• Contents
• Foreword
• Preface
• Acknowledgements
• 1 Medicine: Remembering the past, looking to the future
• 2 Entry requirements to medical school
• 3 Your school’s perspective
• 4 The interview
• 5 How to choose a medical school
• 6 Graduate entry medicine
• 7 Student finance
• 8 The medical student years and how to survive them
• 9 The foundation years
• 10 Choosing general practice (primary care)
• 11 Career pathways in medicine and surgery
• 12 Choosing hospital medicine
• 13 Ethical issues in modern medical practice
• 14 An alternative career in medicine: Medical journalism
• 15 Academic medicine