The Clinical Transaction: Themes and Descants

THE CUNICAL TRANSACTION: THEMES AND DESCANTS JEREMIAH A. BARONDESS* The basic unit of medical care is the interaction between the individual patient and the individual physician. This interaction is generally oriented around the patient's complaints and is structured in such a way as to be medically useful in their resolution. I have chosen to characterize this central element in medicine as the clinical transaction, in the sense of a transaction as an activity conducted so as to reach a conclusion of some type, that is, a purposeful event. The modern physician carries on his work in a period that can reasonably be referred to as the bioscientific era in medicine; it is a time dominated by extraordinary development of the science base of biology and medicine and, in the clinical arena, characterized also by an elaborate new technology. These changes began to gather many years ago; the new bacteriology of Koch and Loeffler, the cellular pathology of Virchow , and the developing experimental method of Claude Bernard, for example, were sufficiently developed in the late nineteenth century to attract William Henry Welch, Francis Weld Peabody, and other young Americans bent on academic careers and aware ofthe promise ofscience for the future [I]. The importation and ensuing development of scientific medicine on this continent [2] culminated in the explosive development , in the past 30 years or so, of a rich cellular and molecular biology which has transformed medical education and practice. On the educational level one important result has been domination of the medical curriculum by bioscience and technology; at the clinical level a major correlate has been the emergence of a phénoménologie view of the sick person. Paper presented as the Distinguished Lecture in the Medical Sciences, University of North Carolina School of Medicine, Chapel Hill, North Carolina, March 22, 1981. The author thanks Dr. John Crow for the long association which has helped in the development of many of these concepts and for his helpful review of the manuscript. * Department of Medicine, New York Hospital-Cornell University Medical Center, 449 East Sixty-eighth Street, New York, New York 10021.© 1983 by The University of Chicago. AU rights reserved. 0031-5982/84/2701-0354$01 .00 Perspectives in Biology and Medicine, 27, 1 · Autumn 1983 | 25 This period of marked flowering of biomedical investigation has occurred as successor to one characterized primarily by a strong clinical tradition which had been developed especially in Western Europe in the seventeenth, eighteenth, and nineteenth centuries. Building on the descriptive natural history ofdisease taught by Sydenham and the model of the physician as naturalist propounded by John Hunter, the meticulous clinical medicine of Corvisart and his pupil, Laennec, and of Skoda, Graves, Stokes, Louis, Hodgkin and their confreres and students followed [3]. Despite the beginnings of medically relevant bioscience in the great laboratories of Europe, however, advances in understanding of disease, even as late as the first decades of this century, had had no significant impact on clinical care. The lack ofa substantial scientific and technologic base for clinical practice, combined with the skill and influence of the great clinicians, gave impetus to the paradigm of bedside expertise as the ultimate expression ofa physician's excellence. Through the first half of this century, in fact, the acquisition, sharpening, and extension ofclinical skills were a primary focus ofeducation and training in American and Western European medicine, and the most prominent academicians and practitioners of that time were celebrated particularly for their clinical expertise. Skills developed to this level were by no means rare 50 years ago and, for that matter, more recently than that. Many who trained in the 1940s and 1950s had the opportunity to learn from senior physicians ofsimilar capacity. Individuals worked to bring themselves to superior levels of clinical skills not simply because, in the absence of a highly developed technology, such skills had to be heavily relied on (although this was largely the case), but chiefly because it was demonstrably true that such highly developed skills were immensely powerful at the bedside. They provided remarkably keen insights into the nature, extent, and progress of a large number of pathological processes and afforded at the same time an interpersonal basis...