The Uncertain Art: Thoughts on a Life in Medicine

“Life is short, and the Art so long; the occasion fleeting; experience fallacious; and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals, cooperate.”

–attributed to Hippocrates, c. 400 B.C.E.

The award-winning author of How We Die and The Art of Aging, venerated physician Sherwin B. Nuland has now written his most thoughtful and engaging book. The Uncertain Art is a superb collection of essays about the vital mix of expertise, intuition, sound judgment, and pure chance that plays a part in a doctors practice and life.

Drawing from history, the recent past, and his own life, Nuland weaves a tapestry of compelling stories in which doctors have had to make decisions in the face of uncertainty. Topics include the primitive (and sometimes illegal) procedures doctors once practiced with good intentions, such as grave robbing and prescribing cocaine as an anesthetic (which resulted in a physician becoming Americas first cocaine addict); the curious “cures” for irregularity touted by people from the ancient Egyptians to the cereal titan John Harvey Kellogg and bodybuilder Charles Atlas; and healers grappling with todays complex moral and ethical quandaries, from cloning to gene therapy to the adoption of Eastern practices like acupuncture.

Nuland also recounts his most dramatic experiences in a forty-year medical career: the time he was called out of the audience of a Broadway play to help a man having a heart attack (when no other doctor there would respond), and how he formed a profound friendship with an unforgettable–and doomed–heart patient. Behind these inspiring accounts always lie the mysteries of the human body and human nature, the manner in which the ill can will themselves back to health and the odd and essential interactions between a bodys own healing mechanisms and a doctors prescriptions.

Riveting and wise, amusing and heartrending, The Uncertain Art is Sherwin Nulands best work, gems from a man who has spent his professional life acting in the face of ambiguity and sharing what he has learned.

"In these essays reprinted, for the most part, from the American Scholar, Yale clinical surgery professor Nuland ponders various aspects of the practice of medicine and patient care. Opening the collection by urging his colleagues toward introspection and self-awareness, Nuland stresses that doctors make life-and-death decisions based on their own emotions, strengths, insecurities and very human needs. In another essay concerning human cloning and manipulating DNA to achieve human immortality, the author suggests we put the brakes on radical technologies whose uncertain consequences we have only begun to contemplate. On a trip to China, Nuland is intrigued by a thyroid operation performed under acupuncture where the patient was wide awake and smiling and suffered no anesthetic aftereffects after a two-and-a-half-hour excavation of her neck. Elsewhere, in an essay on grief written shortly after 9/11, Nuland calls Islamic fundamentalism 'a sickness of the soul,' and in the book's final entry, he himself grieves over a cardiac patient who died while waiting for a new heart. Although solid and perceptive, these essays are also occasionally flowery and verbose, and do not offer the rich insights of the author's bestselling How We Die." Publishers Weekly (Copyright Reed Business Information, Inc.)

Every medical specialty in every hospital has its "professor." Often the oldest and usually the most experienced, the professor is the doctor you call when you can't come up with a diagnosis, when bleeding breaks loose in the operating room and when you can't see the clinical forest for the symptomatic trees. The professor is the doctor's doctor, the go-to person and, when out of earshot, "Mom" or... Washington Post Book Review (read the entire Washington Post review) "Dad."

In the world of medical writing, Sherwin Nuland is one of those professors. A National Book Award winner, he has tackled every conceivable life enigma in his writing, death and aging among them. It would stand to reason, then, that this professor's take on his 40-year career in medicine would be quite the read.

It is. Insightful and profoundly humane, "The Uncertain Art" stands solidly among Nuland's better works. This collection of essays, many of which appeared previously in the American Scholar, is our chance to sit at the feet of the professor.

Nuland is an intellectual omnivore, and so it is hardly surprising that his thoughts on a medical career extend to Thomas Eakins, 9/11, acupuncture and the future of medicine, among other things. But he begins the book with a literary dissection of an aphorism attributed to the original professor: Hippocrates. "Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgment difficult." Nuland peels away the historical layers of meaning encasing Hippocrates' words until at last Nuland's own interpretation comes into relief. "We can deepen our understanding of ourselves, and in this way deepen our ability to help our patients, and add breadth to the value of our days." This appeal for greater reflection is Nuland's clarion call not only for the rest of the book but for medicine in general.

Nuland looks critically, for example, at medical education. He describes the historical roots of American medical pedagogy that created "one of the most remarkable phenomena in the history of science and education," a medical system of worldwide preeminence. He asserts, however, that in its development academic medicine also lost sight of its primary goal, "to teach individual students how to care for the sick." Nuland's prescription, then? To arm young doctors "with a liberal education and a background in humanistic thought." He writes, "The wisdom of any of us is circumscribed by our relatively limited experience of life. We expand it by studying literature, history, philosophy, and the evolution and beliefs of societies not our own." As readers, we cannot help but agree. After all, the professor is a perfect case in point.

There is little doubt that the uncertain art has impassioned Nuland over the course of his career, but writing and words have as well. As in previous books, he offers fascinating deconstructions of esoteric medical terms, and he deftly weaves multiple lines of thought into delicately balanced sentences. But occasionally the literary filigree becomes too ornamental, and you wonder if the professor has turned misty-eyed romantic. At one point, for example, he waxes poetic about basic science researchers: "There is a greatness about many of these people, and a patience and persistence that dwarfs the endurance of all but a few dedicated strivers in other fields. They are the ones about whom Longfellow might have been thinking when he wrote the line ... toiling upward in the night." Perhaps.

But these overwrought passages are few. What fills the pages are Nuland's hopes for medicine. At the end of the book, he writes of his friend George Leyden, a heart transplant candidate. Nuland refers to the courage and perseverance involved in waiting for and receiving a transplant and writes that Leyden was "a step above me, and a step above the vast majority of the rest of us." I agreed with Nuland about his friend, but it wasn't just because of Leyden's courage and perseverance; it was because of his deep belief and indefatigable optimism in the potential of humanity.

Which are also precisely what put this book, and this professor, a step above.

Reviewed by Pauline W. Chen, author of 'Final Exam: A Surgeon's Reflections on Mortality,' now in paperback, Washington Post Book World (Copyright 2006 Washington Post Book World Service/Washington Post Writers Group)
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From a National Book Award-winning author comes this provocative collection of fascinating stories that draws on 40 years of a distinguished career on the front lines of medicine.

A clinical professor of surgery at Yale University, Sherwin B. Nuland is the author of numerous books, including The Art of Aging: A Doctors Prescription for Well-Being; How We Die: Reflections on Lifes Final Chapter, which won the National Book Award; Lost in America: A Journey with My Father; Maimonides; and Leonardo da Vinci. He lives in Connecticut.