The Geriatric Imperative Facing Palliative Care

Abstract

emphasizes the ‘‘process of human thinking’’ in general and especially ‘‘how doctors think.’’ There is a new focus on the humanities as ‘‘patient-centered’’ medicine. For these reasons, Cassell’s new book, The Nature of Clinical Medicine, is both welcome and necessary. In his book, the author’s emphasis on the doctorpatient relationship is a resurrection of an all too absent and much-needed model in medical practice and education: ‘‘caring for the patient’’ in a bedside teaching way. The author is not negating the role of science in the care of patients but trying to demonstrate that medicine uses two kinds of thinking, ‘‘scientific’’ and ‘‘narrative,’’ meaning the impact of disease on the person’s life (the patient’s story). Medicine in this sense is not science although it uses science; it is not only disease centered but also patient centered: ‘‘the embodiment of sickness in a person.’’ The goal of the clinician is to act but also to think, not only the ‘‘what’’ but the ‘‘why’’ of the action in relation to the goal pursued. It is evident that Cassell, a retired internist, spent much reflective time writing this thoughtful book. He uses a case selection teaching format (from real cases) and analysis by a panel of consultants with various degrees of expertise in medicine (medical student, resident, professor). By compiling the commonalities and diversities of opinions in regard to the clinical goals of each case, the author extracts ideas and conclusions exemplified by each case and the accompanying reasoning by the clinicians. As an example, he lists 33 different goals pursued by clinicians across several cases, with each clinician following his or her own set of priorities. Overall, he addresses such topics as care of the dying, prognostication, the importance of values, preconceptions, bias and prejudice, clinical judgment, and knowledge needed to achieve the main goal of medicine, that is, treating the ‘‘sick-patient-in-full.’’ This teaching method stimulates interest and makes for more lively reading. Although captivating, the book contains multiple digressions that create diversion from the topic under discussion and dilute the learning experience. Cassell’s knowledge of clinical medicine and the history of medicine is exemplary, but at times, too many details and cases interrupt our trend of thought. Although not specified for a particular audience, it is clear that it is dedicated to physicians, students, and professors alike, for whom providing the best care to patients is the ultimate goal. It encompasses knowing the personal and medical history of each patient, being open to the goals to be achieved, dissecting all component parts of a decision and contextualizing them, and appreciating the importance of the illness trajectory. Overall, Cassell’s book is an excellent source for reminding us about the central place of thinking in the practice of medicine and represents a path for meeting the challenge of becoming an exceptional clinician.