Dear Marion,

The telephone company relented. The repair that had been promised
for Wednesday evening was accomplished by 2 p.m. on Monday. Here's
my answer to your letter:

You write:
 
> Doesn't the 'Scarlet Letter" paragraph you quoted,
> about Dr. Chillingworth's approach to understanding Dimmesdale,
> come close to describing how you think a physician should approach
> a patient seeking diagnosis, advice and cure? 

No. I respect my patient's personality (Persona is Latin for mask)
more than that. I try to help the patient protect his or her secrets,
both the physical and the spiritual ones even from myself. I quoted
Hawthorne because I read what he published in 1850 as a dramatic
description of the potential doctor-patient relationship as Hawthorne
perceived it in the jmiddle of the nineteenth century. His account is
also a prescient anticipation of the Freudian intrusiveness and
shamelessness that erupted on the professional landscape 45 years later.
Hawthorne in fact depicts Chillingworth as a devil bent on destroying
the Reverend Dimmesdale, the rival who has seduced Chillingworth's wife,
Hester Prynne. Hester in turn is the woman who as punishment for her
adultery was condemned to wear the scarlet letter "A".

> If you're willing to write some more about it,
> or direct me to the relevant sections of your website or elsewhere,
> I would be happy to learn more of your views.

I'm not at all sure that it is worth your while, but on my website
http://home.earthlink.net/~ernstmeyer/glaucoma/glaucoma_index.html
is a list of essays with which I tried (more or less successfully)
to publicize my work years ago. I've lost the text files of the
earlier issues, copies of (most of) which I have in a cardboard box
in the closet. These I would either have to scan or retype before
I could put them on my website. The essays that are on the Web, if
it's worth your while to read them, might give you an idea of how
I learned to interpret and apply the algorithms of diagnosis and
treatment.

> Granted that an open, sensitive, personal relationship
> between physician and patient is extremely beneficial
> in supporting and reassuring the patient,
> and in optimally formulating and delivering advice
> on how the illness can best be handled. 

When there is an early recovery, spontaneous or as the result
of effective treatment, a personal relationship to the physician
is superfluous. When the disease is chronic, debilitating or fatal,
such a relationship is indispensable.

> Yet I understand you to be saying
> that even in analyzing a patient's medical problem in your own mind,
> knowing the patient personally is important. 

Unless the problem is trivial, the physician is likely to do much
damage unless he or she takes into account the patient's subjective
experience of his or her illness.

> Now you don't mean simply having access to the medical record, right? 
> OK, I've learned that you will treat the medical record with scepticism,
> and I guess that's sensible.

I've often reflected on the irony that the lawyer's records,
his "work product", is protected from judicial discovery.
The physician's is not. Mindful of the possibility of being
confronted with his record as an exhibit in court,
the prudent physician now drafts his record as a legal rather than
as a scientific documents, a circumstance which greatly reduces
its usefulness for diagnosis and therapy.

> In contrast to what was available in Hawthorne's era,
> distinguishing between overlapping potential diagnoses
> in modern medical practice is accomplished by interpreting
> the myriad biochemical and cytological tests and visualizations
> that are ordered. 
> Calling this impersonal is an understatement,
> as the patient is shuttled rapidly from one laboratory,
> diagnostician and machine attendant to the next,
> without even the opportunity to see or discuss the individual test results. 
> Yet aren't these diagnostic tests powerful,
> useful tools in analyzing the patient's health problem;
> more effective in achieving an accurate diagnosis
> than would be relying on an intimate personal understanding of the patient
> as an individual? 
> Of course one needn't necessarily choose one course
> to the exclusion of the other.
> If you have the patience, do tell me what you think.

In the past 150 years the advance of technology has produced a sea change
in the way medicine is practised. Technology is now so dominant that the
traditional doctor-patient relationship has been eclipsed. The organization
of hospitals now makes impossible that traditional relationship,
which may or may not reassert itself in non-institutional practice
when the opportunity or the need arises.

Let me experiment with a parable and see how well it fits:

The country is criss-crossed by 673248 streets, each of which
has anywhere from one to 50000 numbered locations, houses,
apartments, building lots, etc. Each of these locations may
be the address of one to a thousand individuals who lives or
works there. There are a thousand million pieces of mail,
much of it unsolicited junk, some of it important personal 
letters, newspapers, scientific journals, newspapers, bills,
statements of account, demands for payment, remittances,
tax and other legal notices, - even crank letters such as
this, requiring to be distributed from one of these addresses,
the return address, to the place of delivery. There are half
a million mail carriers responsible for the distribution.
Among their duties is the identification of mailings which
are misleading or fraudulent.

Consider now the progress of technology; once upon a time
mail carriers were human beings who trudge along the sidewalks
with their heavy sacks from house to house and from street to
street, placing each recipient's mail into the correct mailbox,
and of course, occasionally making mistakes.

But one day the authorities decide that the classical way of
distributing the mail is too expensive and too inefficient.
So on the advice of their management consultants they replace
the human mail carriers with robotic vehicles, steered remotely
by the global positioning system, and equipped with machinery which
will deposit the mail, now neatly packaged and sealed in bright
yellow, unmistakably visible plastic bags, at the roadside of each
specified location as determined by the satellite positioning system.

Mistakes are no longer made. Expenses are greatly reduced, but
there are unforeseen complications, not least in importance that the
addresses turn out to be far from reliable. In fact, many of the
street addresses don't even exist.  The mail carriers were well
aware of this deficiency.  They failed to report it, because they
were paid for delivery even to non-existent addresses, and they
understood that their inability to find the non-existent addresses
would be construed as incompetence or lack of diligence on their part.
They solved that problem simply by redistributing as they saw fit,
mail to be delivered to places that simply weren't there. The consultants 
who designed the computerized delivery, of course, had never themselves 
delivered even a single piece of mail, and the fact the so many of the 
addresseswere non-existent was a secret, not understood, and certainly 
not revealed.

Inasmuch as now the robot deposits the bright yellow bags at the location
where a computer determines that the mail box should be, the landscape
is littered with bright yellow bags of mail that nobody knows what to
do with. Furthermore, the volume of misleading, misaddressed fraudulent
mail has mushroomed. Indeed, because the human mail carriers who vouched
for the validity of the mail have been dismissed, unscrupulous insurance
company executives and bankers now flood the postal system with corrupt
and deceptive advertising.  

To be sure, the managers have anticipated such problems, and have made
it a crime punishable by 10 years imprisonment to send mail to
an incorrect or fictitious address and by 20 years imprisonment to
send through the mails advertising that was fraudulent. But human
nature being what it is, the banks and the insurance companies bribe
the judges not to enforce the laws. Mail delivery, though terribly
efficient has become a nightmare and a joke, and intelligent people no
longer bother to open the mail that is dumped on their doorsteps
by the robots.

The addresses, many of which are fictitious, are the diagnoses of
diseases; the mail delivered is medical and or surgical therapy,
and the mail carriers of course are the physicians who have been
replaced by robots.

It's the season to be merry, and my father would have said:
"Froehliche Weihnachten!"

Jochen