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From Robert Jandl, M.D., Director of Health Services:

Stephen Maturin, the fictional early 19th-century physician, naturalist, and philosopher (from the Patrick O'Brian series of novels), is a fascinating figure. (For those who have not been bitten by the Aubrey/Maturin novels watch out — they are addictive.) As ship's surgeon for the British Navy and close friend of Captain Jack Aubrey, he travels the world, sometimes performing acts of espionage against Napoleon's regime. His world is one of observation, discovery, and intrigue. His immense knowledge of animal, bird, and insect life is constantly expanded as he explores the remote reaches of the world. In the medical arena he is nearly invincible; there is no uncertainty to his treatments, whether he is purging, blood-letting, tranquilizing, amputating, or suturing. If ultimately the patient is lost, it is only because that is the course of nature and there was nothing else that could have been done. In this realm, at least, a good doctor has no regrets.

As I read these books, I marvel at how different the world was then. Ours is a time of great uncertainty and change in the practice of medicine. Financiers and administrators set rules; insurance and government regulations micro-manage routine decisions; the list of potential doctors or "providers" whom patients are allowed to see is restrictive; and daily habits of providing care for patients is being re-engineered in the name of cost-effectiveness and quality control — risking the professionalism, principles, and ethics that have been a part of the practice of medicine for thousands of years.

Stephen Maturin, whose fictional life embodied many truths, had it easy. It is so much more difficult today to know that you are doing the right thing. I wonder, as I read these fabulous books, how it is we know fact from fiction in the dispensing of health advice. On what basis do we say something is a certainty? In real life, a huge amount of what doctors do is based on anecdotes, opinions, or studies with implications and presumptions but no definitive conclusions. One study shows one thing; the next contradicts it. One day we are supposed to eat margarine, the next we are not. Salt is bad for you; salt is not bad for you. Alcohol should always be minimized; one or two drinks a day are good for health. A whole industry of health letters, television commentators, and Internet resources have been created to try and sort fact from fiction. This is not just a problem for doctors. It is a problem for everyone. When a patient calls, it is not always easy to know what course of action is the best, and consequently the patient is increasingly brought into the decision-making process.

Some say that the really smart ones, the "experts," ought to get together and produce practice guidelines to help others know what to do. Some experts do just that. Others say we should only do things that have been proven to be beneficial and not do others — even if they seem to make sense. We call this "evidence-based medicine" and this is happening as well. Still others would argue that it is the patient's life and body: Let them make decisions based upon their own values.

All of these approaches, and others, can be helpful. But it takes great care, patience, and time to stay informed, open to new ways of thinking, and to enter into these lengthy discussions — both as a doctor and as a patient or reader of health advice. In my mind, I sometimes travel to a great ship-of-the-line two hundred years ago, somewhere in the Mediterranean or the vast South Pacific Ocean — with the freedom to do what I think is right, and no more.

Best regards,

"Dr. Bob" (7/25/97)
Rob Jandl, MD

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Read more "Letters from Tripod" in the archive.

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