The art of medicine, said Voltaire, is to amuse the patient until nature heals the disease. Of course, Voltaire lived in the 18th Century when a patient would be lucky if his doctor attempted no more than amusement. This was, of course, the age before antibiotics, anesthesia and a whole host of other innovations that define modern medicine. Today, there is much more to the art of medicine.
Modern physicians have three job to complete in the care of their patients: to make a diagnosis; to offer a prognosis; and to create (and implement) a treatment plan. It may seem that this last task, treatment, is the essential one– the one that defines the doctor’s therapeutic role. Nevertheless, in this book the discussion of therapeutics has been relegated to a small section in the back of the book. This is deliberate. The simplest reason is that this book is aimed at students, doctors-in-training who are charged more with developing a basic understanding of disease than with learning the nuts and bolts of therapeutics. That, for the most part, is the job of residency training; and indeed, no state issues a license for practice to a freshly minted medical doctor on the day of his graduation from medical school.
A second reason that the discussion of treatment does not dominate the book is to challenge the interested student to infer methods of treatment from first principles of patho-physiology. Although “re-inventing the wheel” is a poor strategy for an engineering firm aiming for efficiency, a similar process may be extremely effective for a student wishing to enhance his or her understanding. And even if the treatments that the student invents are to be wrong, the mental work out is no doubt valuable. (Joggers jog for the sake of exercise, not to get to a specific destination.)
The last reason why therapeutics is given such limited space is that this category is the one most likely to need revision. When I entered medical school, the Dean greeted us with the following warning: “Half of what we are to teach you, he said, is not true. The problem is we don’t know which half”. This warning was only partially true. The inaccurate part, I have come to learn, is no so much the magnitude of the of the Dean’s claim (though 50% is probably exaggerated) but rather the implication that we don’t know where these inaccuracies are apt to lie. In fact, the inaccuracies are almost certainly to be found in the realm of therapeutics.
The history of medicine is littered with examples of well-intentioned and well reasoned therapies that are simply wrong—given today’s tools and today’s comprehension of disease. This is not ancient history other: the surgical treatment of gastric ulcers was a mainstay of my third year surgery clerkship 20 years ago. So the discussion of therapeutics does not dominate the book simply because it is least likely to endure.
Another way of looking at this, though, is that the section on therapeutics comes last as it is a congratulatory coda to the field of musculoskeletal medicine. As “wrong” as our therapies are apt to be proven, they are still extremely effective at mitigating human suffering and as such are an essential part of modern medical practice. The modern treatment of musculoskeletal disease has essentially obliterated the word “cripple” from the contemporary vernacular. This following section is one worth studying in detail because it describes methods of great effectiveness. That these methods are imperfect is no secret and no source of shame. Rather, their imperfection should stand as an invitation to the next generation to improve them.