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“But surely, doc, you can fix this. Make her okay.” Here was a grown man who had brought his mother to the hospital after she complained of a headache at home, vomited a couple times, and gradually become less responsive. In the emergency department, scans had identified multiple masses in her brain, likely related to previously undiagnosed metastatic cancer with active coning of the brainstem. The neurosurgery team had evaluated the patient and determined that their interventions would not be helpful at this point.
I shared an imperceptible glance with the rest of our team in the patient room indicating that I would take the lead on this. It was my first week as a Chief Resident, and I was attending on the medicine wards. It was a busy day, and we were on call. I silently reviewed how to break bad news. Her son commented on all the medications available to us as doctors, and that we should be able to do anything. I took a deep breath and started speaking.
The details remain vivid in my mind 6 months later. The son and I spoke for about 45 minutes—about mechanical ventilation, a feeding tube, artificial nutrition and hydration, whether she could hear us, whether she could feel pain, what brain death meant. We went through best-case and worst-case scenarios and ultimately reached a decision to let her pass naturally. The patient died within an hour, surrounded by family, and hopefully pain free. The son remained inconsolable, although understanding. While clearly distraught and desperate for a solution, what struck me was how often he returned to the point about medicine obviously being able to fix everything.
Walking back to the rounding room where the team was ready to discuss our next admission, my mind cast back to an evening 12 years ago reading a hot-off-the-press copy of Harry Potter and the Half-Blood Prince, authored by J. K. Rowling.1 In the book, the newly appointed muggle (nonmagical) prime minister is paid a visit by officials of the Ministry of Magic to inform him that not only does magic exist, but an organization governs its use, and that the good side is fighting a losing battle against the evil side. On learning this, the muggle prime minister exclaims, “But for heaven’s sake—you’re wizards! You can do magic! Surely you can sort out—well—anything!”1(p18) The truth was that magic could unfortunately not sort out everything, and the magical folk admitted as much to the prime minister.
Just like unsuspecting muggles believe that magic is all conquering, patients may believe that medicine has a cure for everything. This is well-meant, and perhaps a testimony to the trust bestowed on the medical community. However, despite all its potential for goodness, medicine is far from perfect. We still do not have the answer to so many questions. Even when we apply what we know, expected and unanticipated adverse events can end up causing more harm than good. Medicine applied in the wrong context or to the wrong patient can have disastrous consequences.
For the outside world, like several of our patients, this would be a revelation. How could medicine not have the answer? How could it turn against them? How could savior become saboteur? I guess one has to see medicine from the inside to clearly realize its limitations and how it can cause harm. What amazes me is how Rowling recognized a similar truth about magic without ever having practiced it (from what we know). Perhaps therein lies her genius. Siddhartha Mukherjee, DPhil, MD, is another favorite author. In his book The Laws of Medicine, Mukherjee described the Harry Potter series as “…a philosophical treatise disguised as a children’s book”2(p7)—I could not agree more. In The Tales of Beedle the Bard, a collection of bedtime stories for educating young wizards and witches, also by Rowling, a line in the introduction reads, “Beedle’s stories have helped generations of wizarding parents to explain this painful fact of life to their young children: that magic causes as much trouble as it cures.”3(pXII)
If the magical folk are doing such a great job educating their children and muggles about the limitations of magic, should we not do the same with medicine for our children—our trainees, and our muggles—our patients? Recognizing these constraints may empower us to better harness the benefits of medicine when applicable. Engaging patients and having honest discussions with them—just like the Ministry of Magic did with the prime minister—and developing curriculum for trainees that openly discusses our limitations—like The Tales of Beedle the Bard—are the pillars of driving this process forward. As lofty as this goal might be, who does not want to match the world of Harry Potter?
Setting appropriate expectations for patients and families who believe in the invincibility of medicine can be challenging. Clinicians can start by seeking to understand what the patient and family desire and are hoping for, but at the same time make clear that our abilities and skills have limits. Using “I wish” statements—“I wish we could make her better,” or “I wish medicine were at that point”—can convey empathy, as well as powerlessness to do everything that we might seek to do.
A suggestion for inclusion in the medical curriculum is not an article, a book chapter, an inspiring speech or a profound quote, but a painting. Several years ago, I entered the office of our Chair of Medicine as a nervous intern for a research meeting to find him gazing at a painting above his desk. He noticed me out of the corner of his eye and asked me to come over and tell him what I saw in the painting. I was glad to see that it actually depicted people, and that he was not conducting a surprise inkblot personality test. After watching me fumble for a few seconds, my mind firmly in the world of “superior vena cava syndrome,” the planned agenda for our meeting, he told me it was a copy of The Doctor, a painting by Luke Fildes exhibited in 1891 in what was then Britain and is now the United Kingdom (Figure).4
Circa 1891. Oil paint on canvas. 1664 × 2419 mm. Courtesy of Tate Britain, London, England. ©Tate, London 2018.
As he spoke, I began to appreciate an experienced physician, face grim and concerned, conducting a house call, sitting at the bedside of a clearly sick child, the room dimly lit, with despondent parents in the background. He explained this was one of his favorite paintings; it depicted the limitations of medicine—antibiotics had not yet been discovered and the child was perhaps septic—and how the “ideal physician” still sat down with the patient and family and shared their hope and despair. Recovery was dependent on the child’s immune system fighting off the infection. The doctor in the painting “did nothing” for the sepsis. What I took away was that it was sometimes acceptable to not have an answer or an intervention, admit as much, and just be there. The art of being present and honest are essential characteristics of a good physician. New drugs, technological advances, genomics, and moonshots will not change that. I am indebted for this introduction to The Doctor, a copy of which now hangs above my desk as well.
Corresponding Author: Arjun Gupta, MD, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8852 (firstname.lastname@example.org).
Published Online: April 23, 2018. doi:10.1001/jamainternmed.2018.0341
Conflict of Interest Disclosures: None reported.
Additional Contributions: I thank my parents, Kumud Gupta, MD, and Arun Gupta, MD; David H. Johnson, MD (the “Chair of Medicine” in this article); Salahuddin Kazi, MD; Elizabeth Paulk, MD; and Ambarish Pandey, MD, for providing feedback on earlier drafts of the manuscript, as well as guidance throughout my career. They were not compensated for their contributions. I thank the patient’s son, as well as David H. Johnson, MD, for granting permission to publish this information. I also thank Tate Britain for granting permission to reproduce The Doctor.
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Gupta A. Harry Potter, Magic, and Medicine. JAMA Intern Med. 2018;178(6):747–748. doi:10.1001/jamainternmed.2018.0341
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