Hocus-pocus: the art of medicine.

Abstract

Mysticism and magic are the roots of medical practice. Centuries of scientific inquiry have produced improved preventive and therapeutic interventions. The history of modern medicine, at least in Western society, appears to be the story of the never-ending struggle of physicians to apply the newest scientific medical wonders to the care of their patients. Discussions ofp values, clinical trials, and statistical methodology are currently common in the halls of medicine. However, we have found throughout our training and clinical experience that a form of magic plays a continuing role in the practice of medicine, even in the setting of maximal technological application. Hocus-Pocus . . . these mystical magical words are commonly used in the practitioner’s magic to transform or to attribute supernatural powers to an object or activity. Although Hocus-Pocus is not part of the traditional medical lexicon, physicians of all specialties are likely to use incantations or ceremonial rituals with similar results. We have made a number of observations on the quality of magic practiced by present day physicians. It appears that the power of the spell at times is dependent upon the specificity of the ritual. For example, in the treatment of intracranial hypertension, hyperventilation is frequently advocated. However, it is interesting to note the certainty with which a consulting physician may recommend a specific PaCO, in the absence of controlled clinical studies demonstrating the utility of this practice (1,2). In the same context, we frequently see the recommended use of corticosteroids for elevated intracranial pressure, while in controlled clinical trials this intervention has proven effective only in the presence of specific intracranial pathology (2). Another example frequently seen is the “prophylactic” administration of lidocaine to patients with acute myocardial infarction. This practice has never been proven to decrease overall mortality (3). One reason Hocus-Pocus remains a part of daily medical practice is the image we wish to portray to our patients, co-workers, and ourselves. “Doing” something allows us to feel “in control.” HocusPocus prescriptions are commonly preceded by the term in my experience when given by consultants. Hocus-Pocus-generated dogmas are taught to physicians in training and become a component of medical practice. Many times it is not until several years later that the absence of a scientific basis for these clinical practices becomes apparent. Thus, many times the magical nature of a clinical practice is unknown to the practitioner. On the other hand, those outside of medicine assume that all medical practice is based on firm scientific grounds. Many would argue that Hocus-Pocus represents part of the art of the practice of medicine, and depriving the physician of this important component of one’s armamentarium would indeed compromise one’s efficacy as a care provider. Physicians have other characteristics in common with the magician. Like the wizard’s robe and hat, the physician’s white coat is an interesting costume, and although magic wands are not standard equipment on the wards, stethoscopes are commonly present in the pocket, whether they are used by the practitioner or not. Hocus-Pocus is a useful part of medical practice and has been recognized as such for generations. The advice to use a new drug on as many patients as possible while it still has the power to heal is variously ascribed to Osler, Trousseau, and Sydenham (4); and Blau has quite bluntly indicated the importance of this part of the medical arsenal when he stated “The doctor that fails to have a placebo effect