Friday, March 20, 2009

Bibliographies as measures of excellence, or, HOW much is that Jaboulay in the window??

I've been thinking a bit about excellence lately, particularly medical excellence. What it is, how to measure it. If it can't be defined, can it still be taught. Inspired by recent discussions at the Collegium for the Study of the Spirit of Medicine, I've been thinking about exemplars and heroes, and how bad boys often wind up being sanitized into role models (think disrespectful young Vesalius, convention-bucking Semmelweis), and the good boys achieve mythic status (think infallible Osler).

Simultaneously, I've been pouring over the various editions of the standard bibliography of classics in medicine, now in its fifth edition and called Morton's medical bibliography. I am startled when I run across a name from OHSU's own history: R.C. Coffey, M.P. Judkins, A. Starr. These individuals seem so real to me that the elevation to near-legend status conveyed by inclusion in such a revered reference work jars my sensibilities.

Much contemporary thinking about medical excellence involves things like "quality assurance", superior physician-patient communication, commitment to ethics. All laudable goals, indeed. But are they synonymous with excellence, or necessary for excellence? What of those deemed excellent by history? Surely, history shall be the judge, right? That's what historians like to think. "Standing the test of time." Almost medieval in its need for the individual to die before the test can be read.

Take R.C. Coffey. He was notoriously difficult to get along with (and was shut out of the medical establishment here in Portland), he was hounded by animal rights activists for his work with dogs, and I doubt his patients liked him much either. But he was an excellent surgeon, a dedicated researcher, a good friend and colleague (to some), and he made a real and lasting contribution to medicine.

Are the definitions of excellence in clinical care different from those in medical research? If so, what to say about clinician-researchers, and the renewed emphasis on bench-to-bedside studies?

I dare say we may not be able to extract a useful summary of qualities appertaining to physicians from the 1991 edition of Morton's medical bibliography: under Medical Ethics, no works later 1900 appear on the list....

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