Management
The physician’s job, said Voltaire, is to amuse the patient until nature heals the disease. Of course, Voltaire lived in the eighteenth century when patients would have been lucky if their physicians attempted no more than amusement. This was the age before antibiotics, anesthesia, and other innovations that define modern medicine. Today, the art of medicine is much more.
Modern physicians have three responsibilities: to make a diagnosis, to offer a prognosis, and to create and implement a treatment plan. The last task, treatment, seems to be the essential one—the one that defines the physician’s therapeutic role. Nevertheless, this textbook deliberately relegates the discussion of management to a small section at the end. The primary reason for this is that Musculoskeletal Medicine is written for medical students, physicians-in-training who are charged more with cultivating a basic understanding of disease processes than with learning the fundamentals of management. The nuances of treatment will be covered in residency training and are, of course, the subject of many other fine books.
The details of treatment are also glossed over, one may add, in an attempt to challenge the student to deduce them from basic principles. Training resident physicians by forcing them to deduce what is already known is certainly impractical, but demanding hard thinking from students is an extremely effective means of enhancing insight. Just as the jogger jogs for the sake of improving fitness and not to get to a specific destination, so too the student may attempt to deduce treatment approaches as a form of mental exercise and not practical training.
The last reason for limiting the discussion of therapeutics is because this category is the one most likely to need revision. When I entered medical school, the dean greeted us with the following jocular warning: “Half of what we are to teach you is not true. The problem is we don’t know which half.” The dean was wrong; he did know which half, or at least he could have made a good guess. If anything we were taught was wrong, these inaccuracies were 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 were, in retrospect, simply off-base. This process of discovering our missteps is not ancient history either—the surgical resection of gastric ulcers was a mainstay of my third year surgery clerkship not too long ago. Accordingly, the discussion of therapeutics does not dominate this book simply because the information in this section is least likely to endure.
Another way of looking at this, though, is that the section on therapeutics comes last as congratulatory coda to Musculoskeletal Medicine. As wrongheaded as our therapies may be proven some day in the future, they are still extremely effective in mitigating human suffering now. The modern treatment of musculoskeletal disease (however flawed) has essentially obliterated the word “cripple” from the contemporary vernacular. This section is worth studying in detail because it describes treatment methods that are extremely effective. 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.
—Joseph Bernstein, MD, MS
