October 30, 2007 - Blind Men Meet Elephant

I read an insightful article today, a New York Times review of a new book, The Surgeons: Life and Death in a Top Heart Center, by Charles R. Morris (Norton). The review, by Pauline W. Chen, is built around an image that describes our ungainly health-care system: the familiar fable of the blind men and the elephant.

The story originated long ago in India. It’s been immortalized in poetic form by a nineteenth-century Englishman, John Godfrey Saxe:

It was six men of Indostan,
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.

The poem goes on to tell how each of the blind men walks up to just one part of the beast. One, touching its side, imagines the elephant as being like a wall. Another, running his fingers along the tusk, describes the elephant as like a spear. Still another, handling the trunk, thinks it like a snake. And so on, and so on. None of them comprehends the big picture.

The poem concludes with these stanzas:

And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!

So, oft in theologic wars
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean;
And prate about an Elephant
Not one of them has seen!

It’s a suitable reproof for those who approach questions of religious dogma with false surety, born of fragmentary experience. Chen, the Times reviewer, deftly applies the story to two aspects of the broken health-care system in our country. The first is the problem – familiar to many patients who have spent time in a hospital receiving multiple tests – of too many specialists and not enough general practitioners. Each specialist concentrates on his or her part of the body. Too often, it’s up to the family-practice physician – the doctor with the least-exalted position in the medical pecking-order, and therefore the least clout – to oversee the patient’s overall treatment and head off problems such as drug interactions and tests whose results cancel each other out.

The second way Chen uses the blind-men-and- the-elephant story is with reference to the competing financial interests – doctors, hospital administrators, insurance executives, pharmaceutical salespeople, attorneys, legislators and others – who are scrambling over each other to carve out their own, individual piece of the health-care pie.

Who looks out for the integrity of the whole system? Too often, no one.

Very often, success in medical treatment is built on mastery of details. That’s why we have specialists. They have the intellect and training to sweat the details.

Yet, there’s also a place – an especially important place – for those with the inductive-reasoning ability to synthesize the details and glimpse the big picture.

Chen concludes by mentioning an “artisanal” value system Morris identifies in his book. The persistence of this value system, despite all the external factors that are assaulting it, is critical to the success of the American health-care system. It’s a time-honored professional value, “one that has little to do with institutional allegiances or administrative management objectives, but rather with ‘internalized systems of ethics and the expectations of other professionals.’ And that, at least for now... may be the part of the elephant that saves us all.”

Artisans in medicine. May their tribe increase.