Can Psychiatry be Both A Medical Science and A Healing Art? The Case for Polythetic Pluralism
Can Psychiatry be Both A Medical Science and A Healing Art? The Case for Polythetic Pluralism
“Not everything that can be counted counts; and not everything that counts can be counted.” —Albert Einstein
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” —William Osler
When I was a first-year resident, a revered supervisor of mine made the statement—half-facetiously—that “in psychiatry, you can do biology in the morning and theology in the afternoon!” That remarkable claim not only intrigued and inspired me—it also became a kind of North Star in my own professional orientation, for the next 30 years. But amidst the intense and sometimes internecine conflicts that rage around and within psychiatry today, I think it is time to reexamine my supervisor’s observation. At the very least, it may be useful to use it as a kind of lens, through which recent arguments about psychiatry may be viewed.
The dilemma faced by the psychiatric profession may be epitomized in 2 e-mails I recently received, both from very well-respected, senior psychiatrists. Senior Clinician #1 is well known in the area of mood disorder classification and in applying the “medical model” and biological subtyping to various forms of major depression. He wrote me in reference to my recent essay “Misunderstanding Psychiatry . . . ,” in which I disputed the claim that psychiatric diagnosis does not make use of objective “signs,” as in general medicine.1 He opined that “. . . psychiatry has rejected the medical model of diagnosis in medical practice” and that the DSM system merely “. . . looks at the list of symptoms and their duration, rejecting [physical and laboratory] examination verifying tests and the validation of treatment responses.”
Senior Clinician #2 argued nearly the opposite point of view, opining that psychiatric residents these days are “. . . being inadequately educated, with an emphasis on . . . [a materialistic] or . . . so-called medical model.” Senior Clinician #2 represents an existential-humanistic approach to psychiatry that seeks to understand the whole person in the context of his or her environment. For him, psychiatry is primarily a “healing art,” not a branch of neuroscience. He argued that psychiatry needs to recognize and realize its true nature “. . . before the field becomes unnecessary and obsolete.”
Can both these respected clinicians be right? Has psychiatry really abandoned the “medical model” (whatever that means)? Does the present DSM framework enshrine or ignore this so-called medical model? Has psychiatry become too focused on neuroscience and “materialist” (usually termed “physicalist”) models of psychopathology, to the detriment of holistic understanding of the person? Or is the real problem our abandonment of the biomedical model in favor of a kind of promiscuous eclecticism? Can our profession ever hope to overcome all these antinomies and develop an Einsteinian, “unified field theory” of psychiatric illness? How might such a unified theory partake of both “biology” and “theology,” to return to my supervisor’s observation? Obviously, this essay can do no more than sketch some very tentative answers to these questions—but here goes.
First of all, what do psychiatrists and other physicians mean by the “medical model”—also called, the “biomedical model”?
Mosby’s Medical Dictionary (8th ed) defines the “medical model” as
“. . . the traditional approach to the diagnosis and treatment of illness as practiced by physicians in the Western world since the time of Koch and Pasteur. The physician focuses on the defect, or dysfunction, within the patient, using a problem-solving approach. The medical history, physical examination, and diagnostic tests provide the basis for the identification and treatment of a specific illness. The medical model is thus focused on the physical and biologic aspects of specific diseases and conditions.” 2
In this sense, the last two DSMs can hardly be seen as exemplars or instantiations of “the medical model.” As McHugh and Slavney3 point out, DSM-III was primarily interested in enhancing diagnostic reliability—essentially, agreement on diagnosis among observers—and not in establishing the biological validity of any condition. Nor have biological factors been a central (or even a peripheral) part of DSM criteria from DSM-III to the expected DSM-5. So it would be wrong to characterize the DSMs as exemplars of “the medical model” or of “biological psychiatry,” as many commentators often claim. Notice, by the way, that there is nothing inherent in this dictionary definition of the medical model that precludes careful attention to the patient’s verbal account of what is wrong, or that “encourages a view of the patient as a machine.”4 These misattributions become important when we consider Dr Nicolas Kontos’s5 argument, below, concerning the “biomedical Straw Man.”
Rather remarkably, Mosby’s Medical Dictionary goes on to note that
“Nursing differs from the medical model in that the patient is perceived primarily as a person relating to the environment holistically; nursing care is formulated on the basis of a holistic nursing assessment of all dimensions of the person (physical, emotional, mental, and spiritual) that assumes multiple causes for the problems experienced by the patient. Nursing care then focuses on all dimensions, not just physical.”2
This is actually an extraordinary statement, and I’ll come back to it when I introduce the concept of “polythetic pluralism”—but on its face, this description of the “nursing model” ought to give every physician pause, particularly psychiatric physicians. Another reason to reconsider the “medical model” is the politico-rhetorical “baggage” this term has acquired in recent decades, as public disenchantment with medical diagnosis—and particularly, psychiatric diagnosis—has grown. Consider this claim from a UK Web site, advocating for the disabled:
“Under the medical model, disabled people are defined by their illness or medical condition. They are disempowered: medical diagnoses are used to regulate and control access to social benefits, housing, education, leisure and employment.”6
“Straw Man” or not, similar claims about the medical model have been voiced by various advocacy groups—and many psychiatrists—highly critical of psychiatric diagnosis and practice. These critics usually use the term “reductionistic” in speaking of the medical model, with the implication that ordinary emotions and “problems in living” are being increasingly and inappropriately “medicalized.”7
Yet it was the psychoanalyst and internist, Dr George Engel,8 who most prominently called attention to the reductionist nature of the traditional medical model, and who called for a new approach—one that would “. . . include the psychosocial without sacrificing the enormous advantages of the biomedical approach.” It should also be noted that “reductionism” in psychiatry is not confined to those who advocate either a DSM-categorical approach or a strictly biomedical approach. As Dr Glen Gabbard9 has observed, “Both [psychoanalysts] and their patients secretly are drawn to simple formulations that eschew complexity.” Reductionism, in short, is an equal-opportunity habit of mind.
To be sure, Engel’s biopsychosocial model (BPSM) has come in for pointed criticism in recent years. Some, like Dr Nassir Ghaemi,10 have argued that the BPSM has led to a sort of mishmash of treatment approaches, in which the psychiatrist adds “a little of this and a little of that” (my phrase, not Ghaemi’s) to the treatment mix, without basing the decision on rigorous evidence. And, in a thoughtful critique, Kontos has argued that Engel himself created a kind of “Straw Man,” by mischaracterizing the biomedical model, eg, as one that effectively discourages dialogue with the patient and “encourages a view of the patient as a machine.” Kontos5 persuasively argues that promulgation of this “Straw Man” model has led to the misperception that “. . . most physicians are purposefully complicit in efforts to promote inadequate patient care.” Indeed, this is a charge often leveled against psychiatrists who supposedly adhere to this bowdlerized version of the medical model.
A complete discussion of the BPSM is beyond the scope of this essay. Nevertheless—while acknowledging both deficiencies in and misrepresentations of the model—the BPSM at least represented an attempt to move psychiatry toward a humane and holistic approach to the patient. It seems to me that Engel must be given substantial credit for this, regardless of his own mischaracterizations of biomedicine or the misapplication of the BPSM by some clinicians.
I have already noted that the DSM framework does not exemplify the medical model as defined above. Ironically, the DSM approach manages to achieve the “worst of both worlds”: it does not adhere to a robust form of the biomedical model, but neither does it provide a rich, coherent existential-phenomenological basis for understanding the patient’s psychology. There are very few diagnostic criteria in DSM that help explain anything important about the inner world of the emotionally disturbed individual. (For a sense of what I mean, I recommend Silvano Arieti’s11 magisterial description of the inner world of the patient with schizophrenia.)
Many thanks, James! I was actually astounded by the Mosby definition of "medical"vs. "nursing" models. Even if we assume the distinctions are wrong or exaggerated, it is extraordinary that a key reference text is promulgating this difference in approach. I think our profession needs to ask itself, how did this come about? --Best regards, Ron
I would like to post a correction and a clarification. First, my apologies to Dr. Nicholas Kontos for misspelling his first name...sorry, Nick, and thanks again for the assistance.
Also, I would like to clarify that when I wrote of the "misapplication"of Engel's biopsychosocial model (BPSM), I was voicing my own view, and not representing the view of my colleague, Dr. Ghaemi. My view is that Engel was essentially correct in pointing to the importance of biological, psychological, and social factors in understanding our patients; however, in my view, this core insight was misapplied by clinicians who did not consider how the BPSM "mapped on" to the evidence base for a particular condition. That is, some clinicians simply "stirred in" a mixture of biological, psychological, and social interventions, without considering which interventions are most appropriate and best-validated for a particular condition. Dr. Ghaemi has a more wide-ranging and fundamental objection to the BPSM, and readers are referred to his article (Ghaemi SN. The rise and fall of the biopsychosocial model. Br J Psychiatry. 2009;195:3-4), as well as to his book on this subject, for more details. --Ron Pies MD
I thank Dr. Ruiz for his appreciative and thoughtful comments on my essay. He raises some important and unresolved philosophical issues that underlie any discussion of terms such as "objective", "subjective", "scientific", etc.
Dr. Ruiz observes that "…there is an important difference between studying a material object and a subjective object. The first is directly accessed through our senses in the interpersonal world. The second --the subjective object--, is accessed indirectly through the patient's verbal communication, and by means of our observation of the patient's somatic expressions and behaviors."This is an intuitively plausible distinction, and I am inclined to agree with it, on a "common sense" level. But then, as philosopher Richard Rorty has noted, "…common sense is itself no more than the habit of using a certain set of descriptions." (Philosophy and Social Hope, 1999, p. 51-a book I would recommend to Dr. Ruiz and other philosophically-minded readers).
The question philosophers have asked since the 17th century is whether we can indeed have "direct access" via our senses to anything in the external world (which, for the moment, we will assume exists!). As Rorty notes (p. 49), many philosophers have argued that "…we may never know reality, because there is a barrier between us and it-a veil of appearances produced by the interaction between subject and object, between the constitution of our own sense organs or our minds, and the way things are in themselves…language may form such a barrier…our language imposes categories on objects which may not be intrinsic to them."
Now, neo-pragmatists such as Rorty believe there are ways around these epistemological problems, and I generally agree. But I think we need to be careful in making too sharp a distinction between studying "material objects" and "subjective objects" (e.g., the putative internal "mental" states of our patients). I agree with Dr. Ruiz that "…the subjective life (with all what it means) remains beyond direct access…" but I would suggest that this is also true of the internal states of material objects, at least on the submicroscopic level. We bring various linguistic and scientific "models" to bear upon our observations of these material objects, such as atomic theory, quantum mechanics, etc., but it is not at all clear that we have "direct access" to their inner states, absent certain theoretical presuppositions.
Another way of putting this, as Rorty says, is that "…we shall never be able to step outside language, never be able to grasp reality unmediated by a linguistic description." Neo-pragmatists would add the best we can hope for are more or less "useful" descriptions of the world. This, in my view, is no less true of oncologists or neurologists than it is of psychiatrists-even while acknowledging, with Dr. Ruiz, that the "subjective objects" of our analysis differ from the "material objects" that may be seen in an MRI or under a microscope. We psychiatrists do indeed use our "intuition" to make inferences about the patient's internal states-but, from an epistemological stand point, this is not fundamentally different than using various theoretical models to describe, say, the structure of subatomic particles. In epistemological terms, clinical "intuition" is a model of another person's mind; particle physics, a model of the sub-atomic realm. On the other hand, perhaps we can at least assert that empathy is required for our work as psychiatrists more than, say, in the everyday work of the particle physicist or pathologist!
Dr. Ruiz raises a good point, in wondering how the "polythetic pluralism" I describe differs from the biopsychosocial model (BPSM), "…if this approach [the BPSM] is applied as it should be." I agree that if the BPSM is applied in a way that "maps" onto the best-available evidence, it does not differ dramatically from polythetic pluralism. Both aim for a "holistic" understanding of the patient. But Dr. Ruiz has put his finger on a problem with the BPSM that Dr. Engel did not really address, to my knowledge; i.e., we lack a method for hierarchically organizing the most relevant factors in the patient's psychopathology, as well as a clear method for prioritizing treatments.
We may instead invoke a hodgepodge of neurological, developmental, psychosocial, biochemical and even spiritual factors in our patient's psychopathology, with no clear way of assigning "weights" to these factors. (There are notable exceptions, of course-in a delirious patient with first-onset of visual hallucinations in the context of alcohol withdrawal, we are likely to assign greater etiological "weight" to the delirium than, say, to early childhood traumata). Similarly, misapplication of the BPSM-or of polythetic pluralism-might lead the clinician to "try a little of this and a little of that" in treating the patient, without appeal to controlled studies of what actually works for the condition in question. Here is where we sorely need controlled research! For example, we have very few studies of the optimal "sequencing" of pharmacotherapy and psychotherapy, in the treatment of mood and anxiety disorders (see see Keeton CP, Ginsburg GS: Combining and sequencing medication and cognitive-behaviour therapy for childhood anxiety disorders. Int Rev Psychiatry. 2008 Apr;20(2):159-64.).
I believe that as our young and very imperfect science of psychiatry matures and deepens, we may indeed overcome many of these problems, and achieve a truly holistic, integrated, and evidence-based approach to diagnosis and treatment. Well-that, at any rate, is my hope! Thanks again to Dr. Ruiz for yet another stimulating exchange. --Ron Pies MD
As usual, Dr. Pies posts an interesting and thought provoking essay. I would like to make a tangential commentary on a couple of points.
The first point has to do with the objectivity of science applying equally to a material object (such as a chair, a brain, a planet, etc.) and to the patient's subjectivity (a feeling, a hallucination, an illusion, etc.). Of course, we can study scientifically almost everything if we follow the procedure as described in the given definition of science. But there is an important difference between studying a material object and a subjective object. The first is directly accessed through our senses in the interpersonal world. The second --the subjective object--, is accessed indirectly through the patient's verbal communication, and by means of our observation of the patient's somatic expressions and behaviors. Nevertheless, the subjective experience remains personal to the patient. In this case, what becomes objective --in the interpersonal sphere--, are patient's verbal communication and patient's objective expressions and behaviors (though the interpretations of these expressions and behaviors are subjective: intuitive on part of the clinician). Naturally, we can study these 'objective' phenomenons with scientific methodology. But the difference in studying 'scientifically' these two kinds of phenomenons is quite meaningful, particularly for psychiatry. In spite of the scientific approach, the subjective life (with all what it means) remains beyond direct access. This is why psychotherapy plays an important role in the management of psychiatric problems, and, among other reasons, why the theory and practice of psychiatry cannot be considered a fully "hard" science. Jaspers resorts to the phenomenological method to reach a patient's inner experiences. An essential part of this method is intuition, where the clinician describes what he perceives of that personal world. Naturally he utilizes a patient's history, expressions, and verbal communications as help to realize this intuition, but basically this is an interpersonal and essentially existential experience. The psychopathologist puts these intuitions into concepts that can be communicated and shared.
The second point has to do with polythetic pluralism. No question that a MDM, and most of the major mental disorders, can be conceptualized as a complex system that requires different methodological strategies to understand, and a pluralistic treatment approach to manage. But I am not clear how a polythetic pluralistic approach to diagnosis/treatment differs dramatically from the biopsychosocial approach, if this approach is applied as it should be. Clinicians misuse the latter, and cripple it. The same can easily happen with polythetic pluralism. Therefore the basic issue seems to be to change from diverse psychiatric 'ideologies' towards thinking holistically about mental disorders. Not an easy task --partly, I think, because the etiology of mental disorder remains poorly known, and when we have several predisposing factors present for a particular pathology, we do not have a good way to organize them in a hierarchy of relevance, except pragmatically with the therapeutic evidence at hand, or ideologically if we lack it.
Thanks for this interesting essay.
Fernando Ruiz, MD
from Melvin Gray MD:
Dear Ron,
First, thank you for sending a copy of your excellent essay Can Psychiatry be Both A Medical Science and A Healing Art? Second, I must say that I agree with you, for the most part, but we do have some differences. And third, from my observation under the current medical payment system, I see few psychiatrists who practice-or can-within the bio-psycho-social model. Perhaps I can offer an alternative understanding and explanation to your polythetic theory.
During your exposition you state that there are two kinds of practices: one scientific and the other humanistic or healing. You refer to the latter type of practice as an art. In effect, you're stating that there are two kinds of truth. One truth can be called knowledge, is derived from science, and is empirically grounded by reason (neuroscience is perhaps the most psychiatry). The other truth can be called opinion and is derived from human experiences grounded in the individual that include feeling, intuition, thinking, ethics, relationships, behavior, cultural biographical background, as well as the here-and-now life situation.
The advantage of this two-fold approach is that it encourages diversified dimensions of human experience and meaning, which neither model alone encompasses. The scientific approach can be considered objective and the other, subjective. This basic split between subject and object, fact and value, theory and practice, science and humanity, and knowledge and opinion, is the fatal flaw in the whole evaluation system. As you know, this flaw has existed since Descartes in the seventeenth century, when he proposed the mind-body dualism that is still in active consideration today. We must therefore live with this dualism but can hope that at some future date an accepted analytic-synthetic theory will be found that will be acceptable to medical/ psychiatric practice.
Modern psychiatric theory has drifted to what can loosely be called the "scientific"side of this dualism and is neglecting humanism or subjectivism. The problem then becomes: what is the best way to educate our students/residents? The amount of knowledge necessary to know clinical medicine is enormous. Can we add to this the studies of anthropology, psychology, sociology, ethics, philosophy, etc.?
These disciplines would give students a comprehensive approach to the human condition and hopefully more understanding of their patients, but it's an awesome burden to expect them to master those fields as well as medicine.
In my mind, psychiatry has evolved into a potpourri of pharmacological and non-pharmacological treatment. These are administered by the psychiatrist and/or his allied nonprofessional assistants or professional colleagues. These colleagues include psychologists, social workers, physician assistants, nurse practitioners, ministers, counselors, family practitioners, etc., who render various and sundry forms of therapy. The day of the psychiatric "shrink" is over.
The forms of treatment which the above group administers include drugs, light therapy, cranial stimulation, electric shock, ultra-rapid opioid detoxification, acupuncture, psychosurgery, electric brain stimulation, chelation, wellness, social skill training, social learning therapy, behavioral family management, vocational rehabilitation, videophone consultation, cognitive behavioral therapy, etc.
The humanist therapists, on the other hand, limit themselves to various individual forms of psychotherapy (Freud, Jung, Adler, Sullivan, Horney, Kohut, Klein, etc.): interpersonal; positive; cognitive behavioral; personal transcendence; confrontational; and splinter movements of endless variety.
Can either of these forms of psychiatry survive? The psychiatric-"scientific" therapist can be replaced by the family practitioner writing the prescription and the other para-personal doing the "therapy". The psychiatric psychotherapist can be replaced by the others who do psychotherapy.
I could pick up on so many points in your paper, but that would seem trivial in light of what I've already said.
Beat wishes.
Mel [Melvin Gray MD, Chicago IL]
Note: At Dr. Gray's request, I have posted this, and I hope other readers will chime in, prior to my replying to Dr. Gray's gracious comments. --Ron Pies
I sincerely thank Dr. Pies for the kind and solid response to my comments. He takes the epistemological analysis to a deeper level, with profound philosophical roots. I would like to explore a little bit more this issue, primarily for my own benefit so as to understand better this intricate matter, and because I believe it has connotations for theoretical and practical psychiatry.
Language indeed is fundamental for knowledge, and essential for human life. Language is so important, that in some circles it has been referred as the "Being's home". I feel inclined to agree, in the sense that whatever we learn about the 'world' and 'us' is stored in the social space in the form of words and concepts. To understand properly this cognitive process, I think we have to be aware of our primary condition: 'living-in-the-world' -- a constant process of understanding and learning about the 'otherness' of the world, about 'myself', and about 'ourselves' (as we create and share a social space with our fellow human beings). The development of culture, religion, science, and art, are built upon this process through the use of language. We join our culture by learning language and by acquiring knowledge from the human environment. In a way, we may say that we are born on the shoulders of the history of humanity. There is an element in this view that we should not neglect nor disregard, and that is the essential presence of "otherness"as constitutive of our basic living experience - an "otherness" that we conform and shape through language. The world we find when we are born and when we enter the interpersonal space, is the product of the learning and knowledge of our predecessors, structured in words and concepts. If we omit acknowledging the ever-present "otherness" of the primary human experience as fundamental to our understanding and knowledge of the "world", we will easily fall into an exorbitant post-modernistic vision: that only our language and its creations exist, hanging in mere nothingness -an absurd solipsism.
In my perspective, the inside and the outside of man lose the traditional division of me/we and the outside world, because we as live-in-the-world, human beings exist in an intrinsic unavoidable constitutive dynamic union with our surroundings. We elaborate the otherness, and expand it through learning. Therefore, the world of everyday is a 'lived world' structured in language. What lies beyond knowledge remains an obscure mystery we are constantly trying to vanquish, but inevitably we remain within the sphere of our own understanding, expressed in words.
Back to the epistemology for the subjective world of us and our peers, and for the world that surrounds us. As already pointed out, any knowledge we obtain in both areas will have to be stored and communicated in words and concepts. We can indeed study complex 'objects' not directly visualized (subatomic realms, distant galaxies, etc.) by observing and measuring their effects. The same can be done studying mental states and psychological functions and performances. Scientists devise the appropriate methodologies for this purpose, and develop 'models' for understanding the complexity of the matter studied, whether it be atoms, galaxies, brains, psychological processes, etc. These scientific models are subject to test and change according their efficiency in accounting for the observational data, their predictive capacity, their coherence and simplicity, etc. They are never set in stone. The knowledge in psychiatry acquired in this fashion, plus the finding of neuroscience and other disciplines, constitutes a very important body of information for the discipline. However, a subjective part of our patients remains unaccounted for in this methodic, external, scientific approach. The subjective life of our patients is an essential part which plays a quite important role in the practice of psychiatry. This subjective world (feeling, decisions, hopes, meanings, etc.) is accessible through empathy and intuition. This empathic intuitive process also produces knowledge --a knowledge that cannot be easily quantified and measured, but that can be shared in teaching and in narratives, though sometimes is difficult to put in words and concepts.
I think it is worrisome to see the field and study of mental health being limited exclusively to externally measured parameters. I fear we may transform our patients in mere "things". Though we treat them with politeness, we would still be blind to the person that lies behind the signs. I think that beyond the 'externalities' we see and measure, there is a living and feeling person, something that we will never even dream to find simply by studying the quanta, the black holes, or the chemistry of the brain. The "interiority" of an atom -mysterious and interesting- is quietly there challenging our cognitive curiosity. The human "interiority" is a living person, like us. It is a living person with whom we can establish a relationship, and with whom we can share the suffering, the hopes and the mystery of human existence in the process of medical help. No question, psychiatry can be a science and a healing art as well.
Thanks again for the opportunity to talk and interchange ideas about these important and interesting issues.
Fernando Ruiz, MD
Thank you, Dr. Ruiz, for an elegant exposition on phenomenology, which I think has affinities with many writings of Husserl, Merleau-Ponty, and some of the existential philosophers and psychiatrists. Re: "I fear we may transform our patients in mere "things". Though we treat them with politeness, we would still be blind to the person that lies behind the signs"--I certainly agree! I believe that the great physician-philosopher Maimonides foreshadowed these ideas, eight centuries ago, when he said, "The physician does not cure a disease; rather, a diseased person."
Best regards,
Ron Pies
Reply to Dr. Mel Gray:
Dear Mel--
Many thanks for your thoughtful and generous response to my article, which, in no small measure, your earlier communications helped inspire!
I do think we are broadly in agreement on the problems bedeviling present-day psychiatry. I am not sure, though, that I believe there are "two kinds of truth". Or rather, I might re-phrase this as "Two roads to the same truth."This is roughly what Dilthey, Jaspers, and others had in mind, I believe, in the distinction between erklaren (explanation) and verstehen (understanding); and these correspond roughly to the two areas you describe-those of "objective" scientific knowledge; and subjective, intuitive, "artistic" understanding, respectively. Nassir Ghaemi discusses this distinction at length in his book, The Concepts of Psychiatry. I believe-as I think you do-that we psychiatrists and our students need to be comfortable with both "roads" to the same human truth, which is the unified truth of the human person.
I agree that it would be a huge undertaking to equip our residents with this kind of holistic understanding of the human person. My own view is that we need to condense medical school to a 3 year curriculum, and expand the psychiatry residency to a 5 year curriculum, including not only neurosciences, but also philosophy, anthropology, literature and religion! But I admit, this is unlikely to happen, and you are (alas!) quite right that very, very few psychiatrists these days practice in the way I am describing. Nor does our diagnostic system encourage such holistic, broad-based erklaren/verstehen knowledge.
But ironically, Mel, I believe that moving in that direction is the only way we are likely to survive as a medical specialty. Otherwise, I think the "replacement" scenario you describe is likely to materialize. Let us hope and strive for a better outcome!
Thanks once again for your wisdom and perspective on this, Mel. -Best, Ron
Here is a principled, rational, humanistic approach - Excellent job Dr. Pies!
Incidentally, I think there is much to be gleaned from "Mosby's" curious distinction between the medical and nursing model.....