IN THE ART OF MEDICINE, DR. HERBERT HO PING KONG DRAWS ON It is HIS VAST DOSSIER OF PERSONAL CASES AND FIVE DECADES AS
It is extremely rare to find a medical book like this one; published in 2014. It is a book that puts the "human" side of Healing back into the art of modern medicine. I highly encourage everyone to read this book, but especially for those contemplating or proceeding to be part of the medical world. This book is a must read. It will shock many to realize modern technology can only go so far, and without the human touch in healing, a great loss is therefore the result - Keith Hunt
The ART of MEDICINE
HEALING and the LIMITS
by Dr. Herbert Ho Ping Kong
What exactly do I mean by the art of medicine?
I mean, in the first instance, a greater emphasis on the human factor.
I mean bringing three key human senses — sight, hearing and touch— more centrally into the doctor-patient relationship in prevention, diagnosis and treatment.
I mean learning how to become an advocate for patients, both within and without the medical community.
I mean bringing empathy, intuition, out-of-the-box thinking and attention to the entire patient—mind and body.
Dr. Herbert ho ping kong is a senior consulting physician at the University Health Network (UHN) and Chang Professor of Internal Medicine Teaching at UHN and the University of Toronto. His practice has focused on difficult diagnostic problems, for which he has a national reputation. In 2008, he co-founded the Centre of Excellence for Education and Practice at the Toronto Western Hospital, an organization dedicated to improving medical education through innovation and scholarship.
The relationship between A physician and patient is truly multidimensional. Dr. Herbert Ho Ping Kong captures this important concept in the opening chapter of The Art of Medicine when he emphasizes the art of seeing, listening, human touch, empathy, advocacy, recognizing suffering and thinking outside the box. Then, in his remarkable style of clinical narrative, Dr. Ho Ping Kong proceeds to interweave patients' stories with proverb, literary quotation and metaphor to illustrate the relevance of these arts as essential to effective medical practice.
Dr. Ho Ping Kong has dedicated his academic career to educating generations of students and residents in the art and science of internal medical practice. His influence has been indelible on all of us who have been privileged to work with him as trainees and clinical colleagues. I was thrilled to learn he was writing this book, which reflects not only Dr. Ho Ping Kong's unique teachings blending the art and science of medicine, but also the learning experiences of a number of our colleagues, some of them his former students, who share a passion for understanding the personal context of their patients.
One purpose of this book is to provide medical students, trainees and aspiring physicians with insight into the meaning of their profession — beyond the acquisition of technical and diagnostic competencies. All too often as medical students graduate and enter very busy residency programs and ultimately their own practices, they are caught up in the constant pressures of focussing on diagnosing and treating disease. The person who confronts them with illness may become less important to the doctor who is constantly constrained by lack of time, inefficient health care systems, language or cultural barriers — to name only a few challenges of daily practice.
Yet the challenge of seeing beyond the disease to the illness that affects a person is often of critical importance in making the right diagnosis and choosing the most effective therapeutic interventions. The mutual satisfaction of developing a relationship built on trust and respect experienced by both physician and patient underpins the most meaningful aspect of medical practice and the art of healing.
Of particular interest, illustrated in this inspiring text, is that generalist and specialist practitioners describe the same approaches to the art of medicine, implying its universality.
Dr. Ho Ping Kong has created a rare window of opportunity for his colleagues to express their deepest held thoughts and beliefs about why and how they practise the art of medicine. These mini essays, interwoven through the text, provide other perspectives on the art of medicine, by physicians of diverse specialties. As Dr. Peter Singer says, communication and sensitivity can be taught to medical students. Leadership and judgment are perhaps more readily acquired through mentorship and role modelling as exemplified by Dr. Ho Ping Kong.
But this is not only a book for the medical community. Ordinary consumers — users of the health care System — will glean many insights from the analysis of his cases and his views on the critical nexus of technology and patient-centred medicine.
On behalf of all who read and are inspired by this book, I sincerely thank the contributors, and Dr. Ho Ping Kong in particular, for sharing their wisdom and knowledge about the art of medicine — an enduring lesson for all of us.
Catharine Whiteside, M.D., Ph.D.
Dean of Medicine
University of Toronto
What is the art of medicine? It is a concept which is often hard to define, but which is easy to recognize. In his daily clinical practice as a general internist, Dr. Ho Ping Kong (HPK) embodies this art. I am one of his junior colleagues in the Division of General Internal Medicine and have had many opportunities to observe him and to learn from him. As someone with a graduate degree in the social sciences, I sought to explore and understand the different components of the art of medicine, and to make concrete the ineffable qualities that HPK incarnates as a clinician. In this foreword, I will share some of the components of this evanescent art.
Paradoxically, one of the ways in which I came to think about the art of medicine was to invert the phrase itself and to put forward a new trope to define our roles as clinicians: the physician-as-artist. I suggest that as health care providers who practise the art of medicine, we are not simply automatons who implement algorithms. Undoubtedly, we must integrate our knowledge about medical sciences into our practices. But the concept of physician-as-artist forces us to recognize, teach and account for all of the other aspects of our clinical work that HPK intuitively knows and demonstrates. Through this trope, I will describe how the art of medicine encompasses and celebrates practitioners who are creative, imaginative, responsive and compassionate.
The physician-as-artist is creative and imaginative
Physicians must learn to think laterally — to think outside the box as well as within it. Creative thinking engenders novel therapies and novel health care delivery solutions. Physicians think creatively when trying to elucidate a diagnosis in a patient who has a disparate constellation of symptoms. We think creatively when we challenge the status quo and innovate — whether in clinical care, clinical education or health systems reform. The physician-as-artist is also able to imagine herself as a patient, just as an actor in the Royal Shakespeare Company may don Prospero's robe and imagine himself as a magician. What is it like to be hospitalized, to be immobilized, to be confused or to be in pain? How does a patient's particular cultural, personal, social or family history influence their illness experience?
The physician-as-artist is aware and responsive
As physicians, we should be sensitive and perceptive to our own surroundings and to those of our patients. We should recognize and respond to the physical, the emotional and psychological well-being of our patients. This multidimensional model of health is a characteristic that HPK exemplifies and promotes. I suspect that it is one of the reasons why his patients seek to visit him routinely even when they are no longer ailing. He always asks questions about life beyond the physical illness — about families, jobs, travels, joys and sorrows.
The physician-as-artist is affective and embodied
A physician has emotions. Most health care practitioners can recall difficult, frustrating, saddening or fulfilling encounters with patients or their families. To invoke an idea described by my friend and scholarly mentor, social scientist Natasha Myers, we must recognize that we move with and are moved by our patients.1 Furthermore, during medical school and residency, we entrain our bodies in addition to our minds. Although this process is most obvious for surgeons who learn the physical skills of cutting and suturing, it applies similarly to internists. Just as an artist articulates her senses or learns her physical craft, physicians learn procedures, train our ears to distinguish heart sounds and our hands to discern masses or nodes. Physicians should not be emotionally disengaged and disembodied scientific minds. We must pay attention to our own emotions, senses and physicalities in order to attend to those of our patients.
The physician-as-artist has perspective
The notion of having a situated perspective rather than an all-seeing and omniscient one highlights one of the major paradigm shifts in 20th-century thought? It represents the transition from modernism, in which the truth and objectivity of scientific knowledge were assumed, to postmodernism, in which a multiplicity of truths is recognized. Thus, no matter how objective or removed from its object of study a scientist or physician maybe, he always has a situated perspective — one which depends on politics, culture, race, socioeconomic status, etc. Rather than having our physician identities subsumed by a stethoscope (a tool which evolved to both literally and figuratively distance a physician from patients and perhaps even from herself as person), the concept of physician-as-artist draws to attention the individual perspectives that we bring to our practices. In enacting his own art of medicine, HPK simultaneously melds therapies based on medical evidence with experiential knowledge arising from his own perspectives and those of his patients.
To help discern the ART of medicine, I have put forward the simile of physician-as-artist. The physician-as-artist thinks creatively; attends to his own perspectives, emotions and physicality; and listens for, imagines and reflects on the perspectives of others—most notably those of her patients. All of these qualities underscore one of the most fundamental components of physicianship: This quality is one which HPK truly exemplifies. It is a quality which will weave together the chapters in this book as we seek to further understand the art of medicine.
Dr. Lisa Richardson
Division of General Internal Medicine,
University of Toronto
February 2 014
"How are you feeling." Dr. Herbert Ho Ping Kong asked me.
We were sitting in one of our weekly meetings in his corner office. I wasn't his patient at the time; I was conducting an interview for the project that would become this book. It was a question he usually asked as a matter of course and, on this particular winter morning, I was hoping he would ask again.
The truth is, I had lately been experiencing bouts of what I thought was angina pectoris — chest pain — caused by blockages in the arteries of the heart. When I climbed even a short hill, I began to feel an uncomfortable tugging. At first, I thought it must be muscle pain, related to lifting weights in the gym. But muscle pain normally subsides after a few days. This pain persisted over several weeks and had begun to trouble me.
I have a long family history of heart disease. My late father had suffered his first heart attack at age 48. Several of his siblings had been stricken as well. My own electrocardiograms ostensibly showed no evidence of trouble, but these, I later discovered, had been misread.
For several days, I had wrestled with the decision of whether to raise my concern with Dr. Ho Ping Kong. The proper route was to see a general practitioner and solicit a referral to a cardiologist. On the other hand, the holiday season was upon us and I feared I'd have to wait weeks for an appointment. I thus felt conflicted, knowing the protocol and not wanting to jump the queue, but also increasingly anxious about my health.
So when he inquired about my health that day, I spoke up. Dr. Ho Ping Kong then asked a few pointed questions about my pain — when I experienced it, how long it lasted. He then rose from his chair, left the room and returned a few minutes later to advise me that I'd be seeing his partner, cardiologist Dr. John Janevski, the next morning at 8 a.m. for a series of tests.
The news at the end of that day was not encouraging. I had effectively failed the treadmill stress test. Worse, Dr. Janeski's more careful reading of two old electrocardiograms indicated that I had already suffered one minor heart attack, probably five years earlier.
A fortnight later, I underwent an angiogram, an injection of contrasting dye into the heart. The results were shocking to me. It found a 99 percent blockage in my main coronary artery, and 70 percent blockages in the next two largest. Diagnosed with so-called unstable angina, which meant I was liable to suffer another heart attack at any time, I was kept in the hospital and underwent triple bypass surgery four days later.
I was indebted to the teams of doctors and nurses who had acted promptly and with great skill to perform the necessary procedures. But in the first instance, I was particularly indebted to Dr. Ho Ping Kong. His alert response to my complaint, his ability to sense that something might indeed be wrong with my heart, very likely saved my life.
Of course, I already knew how fortunate I and his other patients are. Some years earlier, I had developed a strange set of other complaints, including aching limbs, low-grade fever, chills and crippling fatigue. My family doctor, ultimately stumped about the diagnosis, had sent me to see Dr. Ho Ping Kong.
After a series of meetings and a round of tests — blood work, x-rays, a spinal tap and a session with a psychiatrist to check for possible depression — he offered his best guest: polymyalgia rheumatica, an autoimmune disorder. It was his best guess because there is no definitive test for pmr. It's one of those Grey Zone diseases that are hard either to prove or disprove. I was started on a course of prednisone and worked my way through a reducing dosage for about a year. By that time, the symptoms had virtually disappeared.
By the time he suggested we work together on a book that would encapsulate his views on the art of medicine, I already knew that HPK, as he is widely known, was that rare combination of brilliance and sensitivity. My conviction only deepened during the following months of interviews, as I talked to his colleagues, his patients and some of his students.
I was also able to spend countless hours in his company, listening — fascinated — while he exhumed old cases from his inexhaustible memory and explained their importance. He worked from a large black diary book in which he had jotted down perhaps one seminal fact from a particular case, often just a name. And from that tiniest of takeoff points, he would then soar, expounding in minute detail the origin, evolution and final disposition of the case, including hemoglobin counts and heart rates — even if the case was 40 or 50 years old.
When I interviewed HPK's colleagues, I was struck by two predominant themes — a collective sense of awe about his diagnostic acumen and his ability to forge genuine, human relationships with his patients. Strikingly, the physicians regard the latter gift as no less important than the former. Many other physicians, they note, are often good at one or the other, but few demonstrate Ho Ping Kong's extraordinary facility in both. It represents a potent-bedside combination.
As you make your way through this instructive memoir, I hope that you will share my feeling of how fortunate we are to have even a portion of his vast medical experience and timeless wisdom recorded for the next generations of physicians and patients alike.
Michael Posner February 2014
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish. — Sir William Osier
"So, tell us, Dr. Ho Ping Kong, what do you think about our unit?"
The year was 1968. I was attending the regular Monday morning meeting of physicians at the Tropical Metabolism Research Unit, on the campus of the University of the West Indies in Kingston, Jamaica. Set up by Britain's Medical Research Council, its focus was on childhood nutrition — particularly a disease with a very strange name, kwashiorkor, a form of malnutrition caused by lack of dietary protein — a serious concern in the Caribbean in the years that followed the Second World War. The importance attached to the unit was reflected in the physician named to be founder, the distinguished Dr. John Waterlow.
I was a third-year resident, a minor player. I was doing research, a study — later published in the Lancet — on urinary Acidification in adults with sickle-cell anemia.
The unit's senior scientist was nephrologist Dr. George Alleyne, a powerhouse in the Jamaican medical community and, later, on the world stage as a chairman of the Pan American Health Organization. Most of what Alleyne's Centre was doing was outside my principal areas of interest. But that morning, chairing the meeting, he had asked me a pointed question, and I had never been one to shy away from speaking my mind.
"Well," I began, "I'm not a nutritionist, so I'll confine my remarks to some observations about the ward. It's very clean, and the nurses are very efficient. But I think you are doing something wrong with the babies in those cribs. They don't laugh. They are lifeless ... passive ... inert. They have no animation. I think that's wrong. I think you should lift the restriction on nurses hugging the children. Maybe," I ventured, "you should hug them yourself."
The room fell quickly silent, clearly puzzled, if not shocked, by my candour. The colour drained from Dr. Alleyne's face. I knew I was right, but perhaps had overstepped the bounds of propriety. I left the meeting soon after.
I soon forgot about the incident, immersed as I was in a career that would eventually lead me away from my beloved Jamaica, to Montreal's Royal Victoria Hospital and McGill University, and later to Toronto's University Hospital Network, a constellation of world-class facilities that includes Toronto "Western Hospital," "Toronto General Hospital" and the "Princess Margaret Hospital." Years passed, during which my relationship with Alleyne remained friendly but distant. Although we would occasionally see each other, we never spoke about that day.
Fast forward some 40 years. A Jamaican friend, businessman Ray Chang — chancellor of Toronto's Ryerson University, a Toronto Western Hospital board member and a major philanthropist —was honouring me with a gala dinner for my contributions to medicine in Canada and the Caribbean. Alleyne, now the University of the West Indies third chancellor, had been invited to say a few words and, braving a winter snowstorm, had travelled from Washington to Toronto for the occasion.
To my great surprise, he recounted the story of that morning meeting at the unit — of how I had brazenly dared to tell him and his staff that they were running a poor show. At the time, he conceded, he had been stung by my criticism. "Herbert doesn't even know how hurt we were," he said. But, he continued, "Dr. Ho Ping Kong was right. The children did need to be touched and hugged." In fact, the following year, the Metabolic Unit hired Dr. Sally McGregor, a remarkable physician who would ultimately author some 150 papers on the emotional development of children with malnutrition. The importance of touching became a major theme in her work.
From whence did my youthful boldness derived I'm not sure. I simply felt my opinions were well grounded, both in medical and humanistic terms.
Some years earlier, during my third year of medical studies, a group of about a dozen senior cardiologists and registrars was conducting rounds on the ward. Students weren't formally part of the team, but I had managed to position myself strategically within auditory reach to absorb whatever nuggets of medical wisdom that I could.
As it happened, one of the physicians, a professor of cardiology, noticed me lurking, summoned me to the patient's bedside and instructed me to listen to his heart. I was nervous, but not lacking confidence; I'd been on the cardiac ward for three months and had spent virtually every evening listening to murmurs on all the patients that would allow me to examine them. I approached and applied the stethoscope and, after listening for perhaps 15 seconds, delivered my judgment.
"Sir," I said, "this is an early diastolic murmur. It's very soft, sir, but I think it's aortic incompetence."
"Listen again," he commanded.
So I listened for the second time and reached the same conclusion. "I think I'm correct, sir. The aortic valve is defective."
"What year are you in?"
"Third year, sir."
"You know, if you were wrong and you were in fourth year, I'd fail you."
"I'm pretty sure I heard it, sir."
One of the senior registrars then placed his stethoscope on the patient's chest.
"The student is right," he finally said. "This is an early diastolic murmur."
Perhaps it was that incident that gave me the courage of my diagnostic convictions. In the years since then, I have only rarely relinquished them.
For me, the case demonstrated a critical distinction — the difference between listening and hearing. Every doctor is trained to hear, but not every doctor is trained to listen, to detect the subtle distinctions in cardiac behaviour that may spell the difference between life and death.
Hearing is often passive and automatic. Listening implies a higher level of active engagement. When you truly listen to the heart sounds, for example, you can detect subtle but critical indications of the organ's health — loudness, character, the timing of its cycle, its radial signature and its relationship to breathing.
The same distinction applies to the acts of looking and seeing, as well as to the art of touch. It is not enough simply to touch the spleen or the liver. One must actually palpate the organs — determine the size, shape and consistency in relation to the surrounding organs and tissue.
THE practice of medicine is generally considered a science. In fact, science itself has its roots in medicine. In the modern age, it is science that has taken humankind on our remarkable extended voyage of discovery about the body and the myriad illnesses to which it is prone. In the last century, that journey has been expedited by the increasingly complex machines that survey, map and analyze our veins and arteries, our organs and our brains.
I have now been engaged in the practice of medicine for almost five decades. During that time, I have witnessed extraordinary, almost miraculous changes — stunning advances in our knowledge of the mechanisms of disease; an exponential growth in our understanding of biochemistry; amazing developments in science and technology that have facilitated improved diagnosis, preventions and treatment. Many of these strides were made on the back of our spectacular breakthroughs in medical technology. Yet for all this, I submit, medicine — the word itself derives from the Latin medicina, meaning the healing art — remains as much an art as a science.
The wisest doctors know that science is not omniscient. The science of medicine has limits — and the often-arcane secrets of health and disease do not always yield to the microscope and the test tube, the MRI and the CT scan, the X-ray machine and the Laproscopic probe.
Science itself is, by definition, provisional: our knowledge — the result of testing and retesting — stands until it is overtaken by superior knowledge. A good example, drawn from the world of medicine, is the stomach ulcer. For decades, it was medical consensus that ulcers were caused by poor diet or stress. Now, it is widely believed that at least 90 percent of all duodenal ulcers are caused by bacteria. In the final analysis, physicians know, many mysteries remain — conditions that produce symptoms that have no formal name, disease that has a name but no effective remedy. As the great physician and essayist the late Lewis Thomas once said, "The most solid piece of scientific truth I know of is that we are profoundly ignorant about nature."
Indeed, I would even argue that the more progress we make on the scientific front — the more weapons we accumulate — the more critical the "art" part of the professional partnership becomes.
Among the range of talents needed to be used, perhaps nothing is more important than the human faculties — treating patients with compassion, understanding, empathy and solid clinical judgment. This book demonstrates why this is so.
What exactly do I mean by "the art of medicine"?
I mean, in the first instance, a greater emphasis on the human factor — precisely the sort of humanity that I noticed was missing from the ward of the Tropical Metabolism Unit in Kingston.
I mean bringing three key human senses — sight, hearing and touch — more centrally into the doctor-patient relationship in prevention, diagnosis and treatment.
I mean learning how to become an advocate for patients, both within and without the medical community.
I mean bringing empathy, intuition, out-of-the-box thinking and attention to the entire patient — mind and body — to the bedside or examination table.
And I mean learning how properly to care for patients who cannot be helped, either because their condition is terminal or because, as we see more and more in modern times, we cannot attach a specific name to a specific set of medical complaints.
As complexity increases, and costs rise, and waiting times lengthen, and organizations grow, it has become harder and harder for patients to navigate through what often seems to be a confusing labyrinth — the modern medical system. In such circumstances, it is all the more essential that physicians supplement their vast database of knowledge with the human touch.
In the book that follows, I want to explore these issues from several vantage points — drawing lessons from the archive of my own 50-year dossier of cases; from the point of view of patients with whom I have dealt; and from my distinguished colleagues in Montreal and Toronto, who have their own valuable perspectives on how to add more value to care-giving.
I am writing, I hope, for a dual audience — the medical community at large, particularly the coming generation of young physicians, which must obviously bear the final responsibility for determining the future of clinical practice; and for the general public — patients — who perhaps can use the stories in these pages to seek and obtain higher, more humane standards of care. They need it — and they deserve it.
INDEED THIS IS QUITE THE BOOK!! IT RESTORES THE HUMAN ASPECT TO MODERN MEDICINE. IT SHOWS OUR SPACE AGE TECHNOLOGY DOES NOT HAVE ALL THE ANSWERS, AND OFTEN TIMES IT IS LIMITED.
THEY SAY THE PROOF OF THE PIE IS IN THE EATING; DR. HO PING KONG IN THIS BOOK, PROVES HIS VIEW AND PRACTICE OF THE MODERN WESTERN MEDICINE IS THE ONE ALL SHOULD BE FOLLOWING.
I HIGHLY ENCOURAGE YOU HAVE THIS BOOK AS PART OF YOUR HOME LIBRARY OF BOOKS.