“Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate.”
Hippocrates was a wise man. In an era where the causes of most diseases, even the functions of many organs, were unknown, he made detailed and astute observations that allowed him to become a master of prognosis.
His first aphorism is not often quoted in its entirety. When I first read it, I was struck by especially the last two words, “externals cooperate”. It makes me think that perhaps doctoring a few thousand years ago might have been a lot like today. We aren’t the first physicians to deal with demands beyond those of the clinical circumstances, the patient and his or her family.
I can only imagine who the externals were in Hippocrates’ time, but I am thoroughly familiar with who they are today: They are insurance company doctors and executives, pharmacy benefit managers and others, who say yes or no to our diagnostic and treatment plans. They are the ghosts in the exam room when patients and doctors try to make plans together.
The phrase “experience perilous” seems to imply that the gaining of experience is fraught with danger, but an alternate interpretation is that relying only on one’s own experience can be misleading. Hippocrates often emphasized the need to apply the known science to the practice of medicine.
The central point is that it takes time and effort to learn the art of medicine, which is sometimes glossed over in our fast moving society.
The volume of known science has obviously multiplied since Hippocrates’ time, and we can each know only a small fraction of it. But with all the available information now instantly searchable, we can become dangerous to our patients if we apply things without knowing them well through education and experience.
So, in the spirit of Hippocrates:
The artful practice of medicine requires understanding of the science, technical mastery of the craft, and wisdom
and
Facts can be learned by anyone; experience is earned through years of practice; wisdom is granted to us only if our hearts and minds are open, in our practice of medicine, and in our lives.
A Country Doctor Writes: 
It doesn’t surprise either of us to have made similar observations. For over four decades I have been writing about how I practice medicine (see especially “Healing Through Meeting: How to Survive the Health Care Chaos” online at http://www.HealingThroughMeeting.com). From my chapter on the clinical relationship in occupational medicine:
“Did we somehow complicate clinical relationships in the 20th Century? No, we did it quite earlier. Two and a half millennia ago in his First Aphorism, Hippocrates quite purposely implies third parties may have a strong effect on the processes of diagnosis and treatment. (In the translation of W. H. S. Jones, “Life Is short, the Art long, opportunity fleeting, experiment treacherous, judgement difficult. The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals.” My own loose translation, “Life is short, the art intricate, experiment slippery, decision hard to come by. The physician must be ready not only herself (or himself) to do what must be done, but also to engage the patient or any outsider–even third parties.”)
“By “third parties” (or the equivalent thereof, exothen in Greek) did Hippocrates mean the same as we do by “third parties” or, as we often say, third party payers? Yes, substantially so. Although the language of the aphorism may seem to refer to those who are immediately present, there is no difference in effect if the third party is geographically distant. Today, everyone is present to the occupational clinic by fax or phone. It is foolish to assume that the closed door to the examining room hermetically seals off the clinical interchange. Hippocrates made no such oversimplification, admitting in his very first aphorism that others will be present who can help (or hurt) in the care of the patient. He sees it as the physician’s task to orchestrate all resources, effectively to engage all parties in a constructive rather than in a negative or negligent fashion.
“Hippocrates seems to have offered his diagnostic and therapeutic skills for the sake of the person who was sick or injured, often household slaves who did not have high levels of social status or resources. Their masters paid the fees, perhaps, but could the master dictate processes of diagnosis or treatment? Could the master dictate that the slave must perform particular tasks beyond her or his physical capacities or in such a way that it would prolong or intensify suffering or disability? Probably not; I get the sense from several Hippocratic texts that Hippocrates and his followers focused on the condition and welfare of the patient, looking to enhance cure for the patient’s sake. Disciplined study of anatomy, pathophysiology and epidemiology were aimed primarily toward the recuperation of the sufferer. It is implied that the benefit of others would follow if the patient could recover. Could the master, hypothetically, dictate the administration of lethal doses of poison to avoid an expensive or prolonged treatment? Certainly not.
“All Greek texts, those of Hippocrates himself and those quite clearly from different times, hands and minds, focus on processes of diagnosis, treatment and prognosis, especially on manifestations of disease (their natural history and pathology). There are some metaclinical commentaries on the social context of the practice of medicine (such as this First Aphorism and the famous Oath [which is not Hippocrates’ work at all, but about 200 years later]). Not one word indicates that a master or father or husband could dictate or terminate treatment despite male citizens’ dominant social and economic status. Clinical recommendations for action (judgement) appear to have been the responsibility of the physician.”
Thanks for your work.
Nathan Pollack, MD
nathanpollack@comcast.net
I wonder if Hippocrates also meant something more, other than getting 3rd parties to cooperate, that people should not assume that physicians and medical practice alone are the only answers to health. The role of the physician and what “medical practice” has always been is only one part of healing – as the influence of one’s psychology, family, and environment are often the cause and cure of health problems.