Looking Forward, Looking Back

Last week, on the long car ride home from a ski race in the western Adirondacks, with Kobi totally spent and sleeping in the back seat of the car, I tuned into a podcast about the medical writings of Maimonides.

Maimonides, a 12th-century Jewish rabbi, doctor, and philosopher, exhibited masterful organization and summarization of vast knowledge from various scholarly realms. For instance, he took the entire Talmud, an intricate collection of thousands of pages filled with dense academic debates, and distilled it into the Mishneh Torah—a set of six volumes of systematically organized jurisprudence.

Thanks to Maimonides, Jewish history witnessed, for the first time, a reliable resource to consult for practical questions about the application of Jewish law.

In his discussions on divine and philosophical topics, Maimonides focused on looking backward rather than forward. He delved into revealed texts, recognizing their ultimate authority, and considered his role as one of explication and organization. Concerning Jewish law, he believed that the closer a generation was to Sinai, the closer they were to truth; the further from Sinai, the further from truth.

This principle, according to Maimonides, extended beyond holy knowledge to secular knowledge. He held Aristotle in high regard, along with the Arab philosophers Ibn Rushd and Al-Farabi, both also physicians, viewing their work as expressions of fundamental truths about art, ethics, and human nature.

Maimonides perceived his role in these matters as that of an explainer rather than an originator.

However, Maimonides, being a doctor, recognized a fundamental distinction between medicine and religion/philosophy. Medicine, as a science, is inherently forward-looking. All doctors understand that medical knowledge continuously evolves, with new insights replacing old as experience iterates and accumulates over time.

As Hippocrates put it, The art [of medicine] is long, and life is short. Or, as Maimonides might have put it, When it comes to medicine, the further from Sinai, the closer to truth.

Maimonides authored ten works on medicine, covering topics like Hemorrhoids, Poisons and Their Antidotes, Extracts from Galen, Medical Aphorisms, a Commentary on Hippocrates, and a Glossary of Drug Names.

In the case of hemorrhoids, Maimonides was both way off and spot on. While he attributed them to an excess of black bile (a misconception), he recommended Senna as a treatment — exactly what I tell my patients today!

Even in Maimonides’ era, the major medical authorities were still the ancients: Hippocrates, a 5th-century B.C. Greek physician, and Galen, a 2nd-century A.D. Roman physician and philosopher. As a “modern” doctor, Maimonides found himself walking a fine line – acknowledging their authority while critically questioning their content.

In his book on Hippocrates’ aphorisms, for example, Maimonides debunks Hippocrates’ assertions, displaying a modern, empirical approach based on experience, evidence, trial, and error. Where Hippocrates states that young patients with constipated bowels go on to develop loose bowels as they get old and vice versa, Maimonides comments that this is obviously not true, as any experienced doctor would know.

In this respect, although Maimonides predates the enlightenment by many centuries, he seems to be almost anticipating its radical mindset, forced by real-world practice into a skepticism of authority and tradition that put him at odds with scholasticism, the predominant intellectual framework of the Middle Ages.

In other words, while his religious writings established Maimonides as the main authority of his time, close attention to his medical writings reveal that in some ways he was ahead of his time.

Of course, despite his skepticism, Maimonides had profound respect for Hippocrates and Galen, as we still do (or at least should) today. Certainly, in regard to medical ethics, professionalism, and the nuances of the doctor-patient relationship, the classics have a lot more to offer than Harrison’s Principles of Internal Medicine or Netter’s Atlas of Human Anatomy (do med students even read those anymore?).

If anything, medicine today probably does too much looking forward and not enough looking back. As science forges ahead, we increasingly select for medical students and doctors who live on its cutting edge – trained in STEM and steeped in the lab.

Meanwhile, the core essence of medicine – at least in primary care fields like Family Medicine – remains the timeless clinical encounter between doctor and patient that Hippocrates, Galen, and Maimonides understood so well.

When I was on faculty at Columbia Medical School, I co-taught a course in Narrative Medicine, utilizing literature, cinema, and art to more deeply understand our daily experiences on the wards. One of the texts we read was Leo Tolstoy’s short story, “The Death of Ivan Ilyich.” If a more masterful depiction of what it means for a formerly healthy person to suddenly become ill has ever been written, I have yet to encounter it.

I guess I see it like this: when it comes to understanding medical disease, it’s better to look forward; when it comes understanding human illness, it’s better to look back.

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
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