INFECTIOUS DISEASE SPECIALIST S PERSPECTIVE

Dr. DAVID McNEELY

Dr. DavidMcNeely is an internist, consultant in infectious diseases at the University Health Network and an associate professor of medicine at the University of Toronto.

There cannot be many doctors who can claim what David McNeely can claim — that in the same hospital, Toronto Western, he was born, became a medical student, then an intern, then a chief resident and, after a two-year fellowship in infectious diseases at the University of Florida (Gainesville), a practitioner for more than 35 years.

The son of a customs and excise officer, McNeely said his father — frustrated by working within a large, top-down bureaucracy — urged his three sons to choose a profession that would help them avoid such structural impotence. His two brothers chose law. McNeely chose medicine.

As he neared completion of his chief residency, McNeely still wasn't certain which sub-speciality he wanted to pursue. Toronto Western's then physician-in-chief Abraham Rapoport helped him decide.

"He told me, 'I don't need another cardiologist. I do need someone in infectious disease.' Cardiology is mechanical. Your whole life becomes three vessels and one disease, essentially. Rapoport wanted someone with catholic knowledge and that suited me. I never regretted it. I got to interact with all kinds of disciplines and wasn't just a left lobe of the thyroid guy."

When McNeely departed for Gainesville in the late 1970s, there was only one infectious disease specialist in Toronto. Today, there are 60. The numbers testify to the recognition that the world we inhabit is essentially made up of man and microbes.

Mostly, says McNeely, we live symbiotically. "We adapt or develop immunity. But some creatures are not as friendly and have the potential to invade us." And everywhere but the First World, death by microbe is "still the most common way to exit the planet. Two children in five in the Third World die before their fifth birthday, usually from infectious diarrhea or malaria."

Given what he calls the growing "armamentarium of technology," McNeely argues that the art of medicine is "increasingly relevant." In theory, he maintains, we could now give a series of algorithms to a bright high-school student — sequencing patient complaints, lab test analyses and the latest evidence guidelines —-and "as long as they followed the logic, line by line — the serum ginger ale, the stool rhubarb, the total body MRI — they could take a pretty good cut at diagnosis. That's the science. But is that satisfactory for the patient or for society or even intellectually for the practitioner?"

What is missing is the art of medicine, "taking the human condition in all its variations into consideration. What is the average rate of compliance with pharmaceutics in non-symptomatic conditions? How many people with high blood pressure are actually taking their medication? The answer is it is highly variable and depends on a host of things, not least your relationship with your doctor. But the bottom line is if you get 75 percent, you are doing well. And in some communities, it's 50 percent. Is that the best you can do? Well, if you want to do better, the solution is not in the computer. It's in the art of medicine. It's needed at all levels, but the earlier in the process you are, and the broader your involvement with the patient, the greater the necessity: If your doctor is a catheterizing cardiologist or an anesthetist or a colorectal surgeon, you hope he or she is humane, but the art component is less critical, as long as they are iron-clad competent."

McNeely credits Dr. Herbert Ho Ping Kong with restoring the key role played by the general internist —- an academic generalist with comprehensive knowledge of many disciplines. That need, he says, has grown as the aging population presents more and more cases of chronic and simultaneous multi-system disease.

"Remember, the general wards were a professional backwater when he came here from McGill," he says. "The old standard was that if you had heart disease, you saw a cardiologist. If you had renal disease, you saw a nephrologist. If you had diabetes, you saw an endocrinologist. But what if you had all three? Then you dragged yourself around to all of those offices. And if you showed up in the emergency room, there were big battles, not to look after the patient but to send you to the other guy's speciality. And that often led to willful neglect. Herbert was a major instrument of change and de-compartmentalization. Patients, he argued, needed more holistic treatment. You could not arbitrarily decide that Patient X was a heart patient and Patient Y needed a respirologist. And general internists, he said, were well placed to play the role of quarterback. Training had to become more holistic as well. Now it's the paradigm, but then it was a very tough sell, because it meant resources — for beds, for trainees, for dollars, et cetera."

In the more than 30 years since McNeely began practising, he has witnessed dramatic changes in his field — epidemics of Legionnaires' disease, Clostridium difficile, HIV/aids and, more recently, SARS. All of it, he suggests, underscores the need to understand our patients, not just their symptoms. "It's not being intrusive," he says. "So many things are defined by whether you have used recreational drugs or a needle, or by your sexual preferences, by your travel, by your behaviour. And, as we hugely advance in technology and hugely advance in informatics, we can't afford to lose sight of the patient. You can't take all your cues from what's on a computer screen. Talk to the patient. We're getting better at it, because the patient is increasingly demanding it. And that's a good thing."

McNeely regards his longtime colleague, Herbert Ho Ping Kong, as a representative of a vanishing breed. 

"He's a product of a highly traditional and structured British medical school system that does not exist anymore," he says. "And he grew up in the Jesuit school. There were only three instructions — diligence, diligence and diligence. He has the rigour and single-mindedness that only Jesuits have. He is endlessly patient, with every patient he sees. He is empathetic and sympathetic, especially when there is nothing to be done except ameliorate the disease or control its symptoms, as best we can. Finally, he understands that we can have all the technology we want, but we must always keep striving for excellence and we must keep practising, even if we never get perfect."

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