"Wisdom is the daughter of experience"

So said Leonardo da Vinci in one of his many codices. As I practice more, I find Leonardo more and more apropos. For those who are unaware, I am a practicing ED physician and I have found that no amount of scholarly effort can make up for the simple act of seeing patients-lots of patients. I make diagnosis' today on physical exam that I use imaging to approve of rather than to make for me. I could not have done this out of medical school or residency. I can think of the time I saw a patient and missed a problem-only to see a similar patient years later-link the two-and make the diagnosis. Medicine, practiced well, is the accumulation of time and experience married to a love of humanity. Any missing component will cause the whole enterprise to fail. Art and science must dance together or fail together.

Ironically, one of my heroes in the field, fellow Canadian Sir William Osler, opens his famous "The Principles and Practice of Medicine" with the quote "Experience is fallacious and judgment difficult," by no less than Hippocrates-of oath fame. What am I to make of this apparent dichotomy? Osler knew that every patient was an individuated soul and that while trends exist, people remain unique. My only riposte must be the wisdom of the Greek poet Hesiod-with all things, moderation. Experience can lead to apathy but as with anything else, it depends on how you use it. Humility is important. What a fantastic lack of humility I see around me today! The idea that life is short and art is long-an angst-provoking feeling of mortality-can help promote humility but nothing can be more of a salutary tonic than the hard knock of experience. It is hard-hard to earn and harder to put into practice-but it's also the unsung hero of civilization. It is our collective memory and the motor of the world. It is a tangible link to our ancestors and an olive branch extended to our children. Take this and run! And for God sakes, don't drop the baton. Your children will need it.

And so I see patients and I think of Osler. How would he see them? I know he would observe, auscultate, palpate and reflect. I have tried to do this in my own practice within the confines of a busy level 1 trauma center. Sit down and watch the patient. Is he seated or standing? Eating something? On his phone? In agony? I shake hands-is the grip weak or strong? Is the hand cool? Sweaty? Hot perhaps? Is the patient even able to shake hands? With which hand does he shake mine with? Is their atrophy? Cyanosis? A tremor? Pain? Watch him speak. Observe. Does he stand or sit? Pace the room or lie quietly? Can he speak at all?

I auscultate the heart, lungs and abdomen. I listen for the abnormal sound of blood crashing against the walls of the heart, the crackles of accumulated fluid in the lungs or the soft and musical wheeze of bronchospasm; the high pitched tinkling of a small bowel obstruction; the terror of inspiratory stridor. I love the eyes-the yellow of scleral icterus, the pale conjunctiva of anemia, the cataracts of age and the pterygium of working hard in the field. Fingernails too-the lines of liver disease (Terry's nails), of renal disease (Lindsey's nails), of "good-enough" health (extravagant polish) and malnutrition (Muehrcke's lines), abuse (burns and sequelae of burns, especially to the thumbs) and cancer (clubbing). We all have tells but we don't all see them unless we choose to look and know how to see. An externally rotated leg is weakness. Why? Hip fracture or stroke? Is altered mental status a seizure or an overdose? Maybe both?

Medicine is such a wonderful profession because the answer is usually there, right in front of you...but we have to take the time to look for it. What a strange concept in our hectic, pell-mell world! But I urge you to take the time-sit and listen and observe. In medicine, the patient will appreciate it and for everyone not in medicine, your soul will appreciate the brief tranquility as well.

Whatever else William Osler may have been, he was kind. A letter to his young cousin confirms their devotion to the man. He writes to a five-year old:

Dear little Bea

Chick-a-dee-dee-dee! Chick-a-dee-dee-dee. I hear you singing now. It is Sunday evening 8:00 pm and I see you in your little bed and when I listen very hard I think I can hear you singing. Perhaps it is the little birdies outside. I wish I could see you and be near you. If I had wings I would fly every Sunday to 126 Milton Ave and stay all day with my cherubs. Good bye little darling. Write soon to your loving old Doctor.

Not all medicine comes in pills and bottles but most anything good comes in kindness and love. Osler knew it and I try to keep it close to my heart as well. I hope anyone reading this will as well.

30,000 words into a new novel. It's worth the effort. Thank you for all your support!