The Laws of Medicine Read Free Page B

medicine” (an example: “Law 12: if the radiology resident and the intern both see a lesion on an X-ray, then the lesion cannot be there”). But the laws that I was seeking were not attempts to skewer medical culture or highlight its perversities à la Shem; I was genuinely interested in rules, or principles, that applied to the practice of medicine at large.
    Of course, these would not be laws like those of physics or chemistry. If medicine is a science at all, it is a much softer science. There is gravity in medicine, although it cannot be captured by Newton’s equations. There is a half-life of grief, even if there is no instrument designed to measure it. The laws of medicine would not be described through equations, constants, or numbers. My search for the laws was not an attempt to codify or reduce the discipline into grand universals. Rather, I imagined them as guiding rules that a young doctor might teach himself as he navigates a profession that seems, at first glance, overwhelmingly unnavigable. The project began lightly—but it eventually produced some of the most serious thinking that I have ever done around the basic tenets of my discipline.



LAW ONE
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    A strong intuition is much more powerful than a weak test.

I discovered the first law of medicine by chance—which is exactly as it should be since it largely concerns chance. In the spring of 2001, toward the end of my internship year, I was asked to see a man with unexplained weight loss and fatigue. He was fifty-six years old, and a resident of Beacon Hill, the tony neighborhood with brick town houses and tree-lined, cobblestone streets that abuts Massachusetts General Hospital.
    Mr. Carlton—as I’ll call him—was the Hill distilled to its essence. With his starched blue shirt, a jacket with elbow patches, and a silk necktie fraying just so, he suggested money, but old money, the kind that can be stuffed under blankets. There was something in his manner—a quicksilver volatility, an irritability—that I could not quite pin down. When he stood up, I noticed that the leather belt around his waist had been cinched tightly. More ominously, the muscles on the side of his forehead had begun to shrivel—a phenomenon called temporal wasting—which clearly suggested the weight loss had been recent and quite severe. He stood up to be weighed and told me that he had lost nearly twenty-six pounds over the last four months. Even the journey from the chair to the scale was like crossing an ocean. He had to sit down again afterward to catch his breath.
    The most obvious culprit was cancer—some occult, hidden malignancy that was driving this severe cachexia. He had no obvious risk factors: he was not a smoker and had no suggestive family history. I ran some preliminary labs on him, but they were largely normal, save for a mild drop in his white-cell count that could be attributed to virtually anything.
    Over the next four weeks, we scoured his body for signs of cancer. CAT scans were negative. A colonoscopy, looking for an occult colon cancer, revealed nothing except for an occasional polyp. He saw a rheumatologist—for the fleeting arthritic pains in his fingers—but again, nothing was diagnosed. I sent out another volley of lab tests. The technician in the blood lab complained that Mr. Carlton’s veins were so pinched that she could hardly draw any blood.
    For a while nothing happened. It felt like a diagnostic stalemate. More tests came back negative. Mr. Carlton was frustrated; his weight kept dropping, threatening to go all the way down to zero. Then, one evening, returning home from the hospital, I witnessed an event that changed my entire perspective on the case.
    Boston is a small town—and the geography of illness tracks the geography of its neighborhoods (I’ll risk admonishment here, but this is how medical interns think). To the northeast lie the Italian neighborhoods of the North