I would like to try and establish a tentative program of accomplished medical practice, according to Maimonides’ views featured in his medical works.
Studying and Memorizing the Most Accurate Medical Works
In the Book on Asthma
chapter 13, Maimonides quotes an aphorism of Rhazes, in which he stresses how difficult it is to become a skilled physician. To which he adds:
The more accomplished one is in that science, the more precise his investigations are, the more doubts and difficult questions arise in him.
He will go into additional investigations and will hesitate in some of his answers.
Maimonides also remarks that even if understanding theoretical medicine from the literature may seem easy for someone who is in full possession of his faculties, the application of these notions to a practical case is often problematic, even for a trained and conscientious practitioner.10
As stated above, Maimonides described how hard and tiring his days of work were. Once his practicing was over, he reviewed and checked the difficult cases he had seen during the day, searching the literature that was at his disposal. He thus controlled his memory and checked himself constantly. This left him only the Sabbath for his theological studies, which were formerly his main field of interest.
Discussing Difficult Cases with Colleagues
When Maimonides and his family lived in Fes, Morocco, he saw a patient who was “very strong;” however, after having undergone bleeding, the patient weakened and died the next night. Maimonides notes the following11
: “A learned physician under whom I studied asked me: ‘Do you know the nature of the mistake this physician made in bleeding that patient?’” His teacher then explained that the patient was a glutton whose stomach (the cardia) had therefore been weakened. He should have known that Galen had forbidden bleeding in such cases, for it may cause fainting.12
From this story we learn two things: one, that Maimonides studied medicine in Fes; second, that he discussed practical cases with his teacher—he even quotes in toto the relevant passage from Galen. Both medical experience and remembrance of the adequate literature are thus documented.
Further in the same chapter, Maimonides describes another case, treated by four physicians, “all of them trained in this art.” The Sultan was prescribed theriac, but he died soon after ingestion. Maimonides inquired about the reason for death; he spoke to all the physicians involved, “in order to learn something useful from it,” but none of them answered him.13 Maimonides was in search of the true reason for the death, as formulated in the introduction to his commentary to the Fathers’ Aphorisms (Pirqei Avot): “Accept the truth from whatever source it comes.”
Maimonides moreover explained that his aim in recounting this case was to warn patients—not just physicians—to having recourse to strong drugs (such as theriac) only on the advice of an accomplished physician, and, even then, with great caution, only in case no other treatment may be devised.14
Considering the Patient—Not Only the Disease
One of the central statements of Maimonides is the following:
One should never say: “This disease is similar to that [other] one.” … Nor should one say: “I have seen how my elders have treated [this disease] in such or such way.” [As a matter of fact] a physician does not treat a disease, he rather treats a sick person.15
To which he adds: “Every person who falls ill necessarily requires renewed consideration and reflection.”
Maimonides thus indicates that the constitution and the psychology of the patient must be taken into account. As stated in his Regimen Sanitatis (Heb. Hanhagat Ha-Beriut), Maimonides feels that a psychological assessment of the patient should even anticipate any medical intervention. “For every sick individual feels his/her heart constricted [Heb. libo tsar].”16
In other words, an accomplished physician should know how to adapt his way of addressing the patient according to the latter’s psychology.
Psychology was then a branch of Philosophy, and we thus understand better why even Galen said that a physician should be trained in Philosophy.
Establishing Authority with the Patient and His Environment
In his Commentary on Hippocrates’ Aphorisms
, Maimonides affirms that a physician who aims at doing his best for his patient’s benefit must have in view more than achieving an exact diagnosis and an adequate treatment for the disease. He must care for a full-fledged application of the treatment. Indeed, the patient might be reluctant to take a drug that is bitter or repulsive; and the care-takers might prefer taking advice from some popular quack or from a “wise woman.”17
The physician must therefore endeavor to gain full confidence from both patient and care-takers. Moreover, he should feel responsible for the removal of any impediment to the treatment; he should even help poor patients to purchase the drugs and/or to move to some healthier accommodation.
The duty to help poor patients applies to every individual, including physicians, but Maimonides feels a necessity to mention it here (cf. Hilkhot ‛Aniyim 10, 4–5).
According to Hippocrates, an effective way of gaining the patient’s trust is through accurate prognosis. We read:
I hold that it is an excellent thing for a physician to practice Prognosis. For if he discover and declare [sic], unaided, by the side of his patient, the past, and the future, and fill in the gaps in the account given by the sick, … men will confidently entrust themselves to him for treatment.18
In other words, the physician will thus show that he has full knowledge of the disease, even more than the patient is able to remember.
In this context, we can now better understand Maimonides’ statement in the Book on Asthma: “When the physician perfectly masters his art, then one will readily deliver his body and soul into his hands, and let him guide them according to his views.”19 This indeed conveys full confidence.
According to Maimonides, a physician should, in order to attain perfection, or at least to strive at getting close to perfection, first master and memorize theoretical medicine; second, check carefully the relevant and trusted sources and/or discuss difficult cases with well trained colleagues; third, consider each patient individually, carefully weighing diagnosis, prognosis, and treatment; and fourth, gain full confidence of the patient and his environment.
We may argue that a number of these rules are quite relevant to actual medical education. They include patient-oriented medicine, fruitful collegial relationship, and continuous medical education.