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Rekindling the Practice and Art of Medicine

02/27/2020 8:53 AM | Anonymous

By Steven Reames

At the 61st Annual Winter Clinics this year, we enjoyed the thoughts and research of a world class physician speaker with an emphasis in the humanities alongside the more clinically focused topics by local and regional specialists. It made for an interesting juxtaposition of left and right brain thinking.

Some physicians may remember the name Dr. Salvatore Mangione because of his well-known book Physical Diagnosis Secrets.  In fact, one physician commented that she kept the book close to her all the way through residency. Trained in pulmonology, Dr. Mangione is currently an Associate Professor of Medicine at Thomas Jefferson University. In part because of his Italian upbringing and education, he has a strong interest in the historic, poetic, and artistic as it relates to medicine.

Leading off with “The Art of Observation and the Observation of Art,” Dr. Mangione underscored the importance of a skill that astute physicians use every day to make effective clinical diagnoses: the Zadig Method. It was first pioneered by Italian physician Giovanni Morelli, practiced and taught by Dr. William Osler, and epitomized by Sherlock Holmes, a character modeled in part on Edinburgh surgeon Joseph Bell.

Mangione illustrated it by exploring the painting “A Portrait of a Lady,” which hangs in the Philadelphia Museum of Art in his home city. If you did not know any better, one might think it would be more aptly titled “A Portrait of a Somewhat Homely Lady.” But with a deeper knowledge of 15th century Venice, Renaissance portraiture styles, and close examination of her physical features, one can actually deduce quite a bit.

Dr. Mangione observed:

  • Based on the color and style of her clothing, her lack of jewelry, and her headscarf, she is most likely one of the 11,000+ tax-paying prostitutes in Venice at the time.
  • Although the color of her face could indicate the use of rouge or perhaps even indicate secondary syphilis, knowledge of how and when make-up was used and when the STD appeared in Italy disfavors that conclusion.
  • More likely, the skin-rash, her receding hairline, and wispy red hair supports the possibility of lupus. This is further evidenced by a swollen right eyelid and a noticeable goiter.

The accurate rendering of these features, Mangione pointed out, predates Cazenave’s report of lupus érythémateux by almost 400 years. Does art have something to teach doctors about the importance of being more observant? You bet.

In another talk, Dr. Mangione explored 11 different archetypes which physicians have fit into over the centuries. He explained that to have the greatest impact in our communities and societies we must not think of the profession as a one-dimensional technician of science. He did a deep dive into some of the roles by profiling three physicians:

  • The Physician as Poet – Canadian Col. John McRae, whose “In Flanders Fields” is the iconic WWI poem written as a plea by the dead to the living to not let them die in vain.
  • The Physician as Humanist – William Osler, who revolutionized medical teaching in North America, wrote before his death, that grievous damage “has been done by regarding the humanities and science as anything but ’twin berries on one stem’”
  • The Physician as Philosopher - Rita Levi-Montalcini, one of 12 female physicians to receive the Nobel Prize in Medicine, hers for the discovery of Nerve Growth Factor. Her career included not just medicine, but also as a Senator for Life appointee in Italy and an outspoken advocate on human rights.

In his banquet keynote speech, “Leonardo at 500,” Dr. Mangione pulled nine lessons in creativity from the life of Da Vinci, on whom he has clearly done extensive research. In fact, he has published a few articles on the man considered to be the most creative to have ever lived. In a 2019 American Journal of Medicine article, he makes the case for how Da Vinci’s likely dyslexia led to him being such a great visual thinker.

Once again, the talk emphasized the need as physicians to balance the best of scientific advances with some seemingly non-scientific principles such as humor, ambiguity, and idleness. He argued it is out of these qualities that Leonardo’s great creativity sprung. Combined together, Dr. Mangione’s wide ranging talks resonated with what many physicians are feeling today: the practice of just pure medical science as a widget in the cog of healthcare without the time or permission to feel and be human is deleterious to a calling as healers.

If anything, Winter Clinics punctuated the need for physicians to reclaim medicine from owners, managers, and governments who may not share the same deep humanistic impulses that led many to medical school. It was important for attendees to explore innovations in cardiology, point of care ultrasound, cancer, and internal medicine; to talk about using tele-health to deliver care to rural areas; and to think about the possibilities that genetic testing holds. But my overwhelming takeaway was that science will not help us answer the ethical questions that arise in the practice of medicine. Those dilemmas, Mangione said, can only be addressed by looking backward at the rich history of poetry, literature, art, and philosophy expressed over the past few millennia.

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