On the Art of Medicine and War by Steven Vaughn MD

Every country with a military force prepares a set of coherent statements about doctrine to follow in war and peace.

“Military doctrine is the expression of how military forces contribute to campaigns, major operations, battles, and engagements. It is a guide to action, rather than hard and fast rules. Doctrine provides a common frame of reference across the military. It helps standardize operations, facilitating readiness by establishing common ways of accomplishing military tasks. Doctrine links theory, history, experimentation, and practice. Its objective is to foster initiative and creative thinking. Doctrine provides the military with an authoritative body of statements on how military forces conduct operations and provides a common lexicon for use by military planners and leaders.” (Wikipedia, military doctrine.)

In comparing war and many other things, there is clearly a culture or convention of how certain things are done, that may not be officially stated in terms of doctrine. They may arise in a communal, lassez-faire way, as was the way of American medical practice up until the 1990’s.

For the last 25 years, there has been a clear change in the doctrine of both the military and the medical profession in the United States. The doctrinal changes in the military were overt – they were driven by the end of the Cold War, and designed to maximize flexibility, fluidity and responsiveness in military operations.

The changes in medicine have been nearly the opposite. The doctrine has changed from fostering direct and interpersonal relationships between patients and professionals, to that of the retail/industrial method, with less individual flexibility and responsiveness.

Unlike for the US Military, which publishes all its doctrinal publications online, the drivers and participants in the change in medical doctrine have been invisible. In the same way that the grunts on the line are not invited to the discussion of military strategy, the practitioners of actual healthcare are not invited to the strategy-planning table. If anything is conveyed to us, it is the assurance that a diffuse, formless and headless “spirit of the moment” is guiding vast changes in healthcare; changes that are only logical and reasonable, changes which are opposed by only the most selfish and contrary forces, such as physicians.

As the flagrant incompetence of the last 25 years of reform has sunk in, and the system has become more and more incompetent and terrible, unable to provide care and hurting people, the blame is laid on the “counter-revolutionary” forces that are selfishly and cruelly slowing down reform. The “spirit of the moment” assures us that reform is not working because it is going too slowly.

The current state of medical “reform” reminds me of a conflict between two 18th century military theorists, von Clausewitz and Jomini. The US military has shifted away from Jomini to Clausewitz; the medical doctrine has shifted away from Clausewitz to Jomini.

There is a pretense that no experience is necessary any more in the delivery of medical services. Any clerk can deliver the goods, trained by the twin forces of the pharmaceutical industry and the university (which are becoming less and less distinguishable.) Medicine can be conducted by simple and fixed rules; creativity is undesirable, as a lack of standardization, which by definition is inferior care.

Clausewitz energetically spurns the concepts behind “scientific warfare,” fixed and formulaic:

“It is only analytically that these attempts at theory can be called advances in the realm of truth; synthetically, in the rules and regulations they offer, they are absolutely useless.

They aim at fixed values; but in war, everything is uncertain, and calculations have to be made with variable quantities.

They direct the inquiry exclusively toward physical quantities, whereas all military action is intertwined with psychological forces and effects.

They consider only unilateral action, whereas war consists of continuous interaction of opposites…. Anything that could not be reached by the meager wisdom of such one-sided points of view was held to be beyond scientific control: it lay in the realm of genius, which rises above all rules.

Pity the soldier who is supposed to crawl among these scraps of rules, not good enough for genius, which genius can ignore, or laugh at. No; what genius does is the best rule, and theory can do no better than show how and why this should be the case.” Von Clausewitz, On War, Book Two, Chapter 2.

I find it fascinating that the United States Military, which can be assumed to be an institution that favors order and discipline, is racing away from the mindless implementation of rules in the conduct of war, as Clausewitz warned; and that American medicine is racing to embrace the sterile, rules-based approaches to practice, deserting fluidity, flexibility and experience which were learned on the field of battle in military operations.

Who writes the doctrine for the US Medical world? Or is it really just a “spirit of the moment,” not driven by anyone’s selfish interests, spontaneously arising from the masses? If you’ll buy that sort of nonsense, you deserve what you get.