Medical Practice in a Changing World: Reflections From the 19th Century.

Throughout the past decades, we have witnessed profound changes in medical practice and medical teaching. These 2 indissociable features of medicine have continuously and deeply influenced each other, and, to a larger extent, they have shaped the way in which medicine is perceived by society. In a time when the rhythm of change in medicine and society continues to increase, it is important to reflect on these far-reaching pivotal concepts as we see a rapid evolution in the dynamics of social interaction and a major and ubiquitous impact of technology in medicine and society.1, 2, 3

One of the most iconic works by the Spanish-born master Luis Jiménez Aranda, Hospital room during the visit of the chief of staff (Figure 1), is a remarkable painting, which highlights several of these features and shows the revolution of medical practice and medical teaching in the previous century. This masterpiece carefully depicts several details of the practice of medicine during the 19th century and was probably inspired by a visit from Luis Jiménez Aranda to a contemporary French hospital. In this work, we can observe a senior doctor assessing a patient while being observed by several younger physicians. The markedly asymmetrical relationship between the senior doctor (the “chief of staff") and the other individuals is elegantly represented. While he is examining the patient, there is a visible gulf between him and the younger physicians, who observe him attentively, trying to capture all the details. The painting also reflects another aspect of medical practice at that time: the practice of “eminence-based medicine,” as opposed to the modern and essential concept of evidence-based medicine.,

Figure 1

Luis Jiménez Aranda, Hospital Room During the Visit of the Chief of Staff: Museo del Prado, Spain, 1889

Reproduced from Wikipedia. This photographic reproduction falls within the public domain.

With a closer look at the painting, especially to the way how the patient and the doctors seem to interact, it is also possible to reckon the characteristics of the doctor-patient relationship. The painting illustrates the distant and paternalistic nature of medicine, so characteristic at that time, which considerably changed across the decades, being significantly different nowadays. This concept is also echoed resolutely in another painting from the same period, the well-known masterpiece by the also Spanish-born Pablo Picasso, Science and Charity, which is considered an icon of the practice of medicine at that time.,

The painting also lavishly illustrates the unidimensional nature of clinical practice at that time. Beyond the senior physician and his students, no other healthcare professionals are depicted in the main scene. This contrasts with the current view of comprehensive patient management in a multidisciplinary setting, which is applied to several fields of medicine.

Another remarkable aspect, which immediately raises the attention of the observer in this painting, is the senior physician performing direct auscultation to the patient. It should be noted that this work is dated from 1889. At that time, the stethoscope had already been introduced by René Laennec more than 50 years earlier and had already undergone its first updates in design and functionality, ushering in a new era in terms of the physical examination. It is interesting to observe how, now and then, the incorporation of new technologies into medicine lags in time (sometimes decades) between their discovery and their implementation in clinical practice, reinforcing the importance of a new field of medical knowledge called implementation science in healthcare.

More than 100 years later, we are now living a new revolution. Just as in the late 19th century the introduction of the stethoscope brought a revolution to medical practice, nowadays the incorporation of insonation and ultrasonography (especially with the use of pocket echosonography) can be considered the fifth pillar of the bedside physical examination, as recently suggested by Eugene Braunwald.

Last, but not least, the painting depicts the evolution in terms of hospital design, a topic deeply intertwined with several core concepts such as patient privacy and perception of care. In this painting the artist skillfully details in the foreground (on the left) another patient who can be seen gazing directly at the senior physician as the medical examination unfolds. Beyond this, the stark and austere environment in a common room with patients directly visible by their counterparts (namely, in the absence of divisions between adjacent beds) should also be noted, in contrast to contemporary views on hospital design. This point once more underscores the importance of an integrated approach to healthcare, inasmuch as the design of facilities (a topic involving many subjects, several of which are not directly related to clinical care per se) can have a major impact on the physician-patient relationship and on the overall treatment of patients.,

In the current era, when several challenges, including the ongoing COVID-19 pandemic with its disruptive worldwide impact, have disrupted the status quo of medical practice and teaching, rethinking this binomial element is paramount to face the hurdles that still lie ahead., As new and more inclusive models emerge and continuously adapt and evolve, the messages contained in Aranda’s painting remain thoroughly relevant, allowing a window for reflection on past paradigms as we shape a more comprehensive, and humanistic, shared future horizon in the practice of medicine.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.