Essay on the art and science of medicine which I very assiduously recycled

This is one of those pieces that I read now and think "ah, youthful idealism..." corny as that sounds. It won me the Irish College of General Practitioners Shepperd Memorial Prize in 2001, was published in the New Statesman in a version, and also I published a longer version in the University Observer. the art and science of medicine “The practice of medicine in its broadest sense includes the whole relationship of the physician with his patient. It is an art, based to an increasing extent on the medical sciences, but comprising much that still remains outside the realm of any science. The art of medicine and the science of medicine are not antagonistic but supplementary to each other. There is no more contradiction between the science of medicine and the art of medicine than between the science of aeronautics and the art of flying.” - Francis W Peabody From the most cursory glance at the newspapers and from even the most inattentive listen to the news, it’s obvious that the medical profession faces many and varied challenges. Yet while the logistical, political and organisational issues that face us are severe, the most profound challenge facing General Practice and medicine in general is a philosophical one. Where once medicine was seen as the royal road to a safe, respectable position in society – along with the priest and the teacher, one of the three traditional pillars of a stereotypical Irish community – now most people all too aware of the problems facing the profession. Perhaps the first issue any lay person would identify is the system where doctors in training work hours that take on the qualities of Dantean torment. It’s undeniable that many intelligent and compassionate people, who would make excellent doctors of every sort, but perhaps particularly GPs, are put off from even considering medicine by this situation. As the old system whereby a medical graduate could simply set up as a general practitioner are replaced by structured training schemes, the situation in hospital medicine profoundly effects GP training. The changing demographics of medical school intake is another challenge to be faced by medicine. Increasing numbers of women in the profession will face a career structure still rooted in the days when fathers were all too often strangers to their families. Ireland is occasionally called the “51st State of the Union” because of the high number of incidents of medical litigation that take place here – it’s estimated that Irish doctors are four times more likely to be sued than their English colleagues, and eleven times more likely than Hong Kong doctors. Does this lead to the practice of a risk-averse, defensive medicine; does it destroy the relationship of trust between doctor and patient? There are signs that the political will is there to establish a less adversarial process for resolution of disputes; I personally know many people who would make excellent doctors who are put off not by the prospect of long hours but of being sued while trying to help their fellow human beings. And doctors will have to face the changing public perception of doctors – high profile scandals both here and in the UK involving not only malpractice, professional arrogance but also deliberate homicide have strongly affected the public imagination. I earlier referred to the “pillars of the community” that were the priest, the teacher and the doctor – all three have fallen from their eminence. We are constantly told that Harold Shipman was an isolated case, but an isolated case that murdered at least fifteen and probably over two hundred of his patients will certainly crack public confidence in all doctors, but especially in the General Practitioner. Perhaps as a function of this increasing public climate of assertiveness and scepticism, many patients will now supplement the information they get from their GPs with research on the Internet, from sites of varying quality. As primary health care providers, General Practitioners are faced with these issues on an ever-increasing basis. In the rest of this essay I would like to deal with what I believe is the most fundamental issue facing both general practice and all of medicine, not only in Ireland but internationally, in the future. This is a more philosophical, the cynical would say a more airy-fairy, point; but one that has a vital relationship with general practice and indeed all of the issues above. It is the fundamental question, what is a doctor? Presumably something more than an individual with the required qualification and certification, who pays the appropriate annual retention fee to the Medical Council and displays their certificate of registration. During the narrowly-averted junior doctors strike, we could see in the public pronouncements of many NCHDs a drift away from the sense of medicine as a vocation to a more hard-headed view of it as a job like any other. In fact, many of those interviewed responded with anger and derision to the notion that medicine was a vocation; many referred to the market value graduates of their status would have in the private corporate sector. The beloved cliché of lazy feature writers and pundits, the C***** T**** (I refuse to give further exposure to the defining phrase of our time) has had far-reaching, and in some respects very positive, effects on Irish society. But as Puff Daddy and the Notorious B.I.G. put it, mo’ money, mo’ problems, and whereas once medical graduates had the ego boost of knowing they had well-paid, prestigious employment, now they look at their contemporaries working in the sexy industries de jour, Information Technology and the wonderfully vague Management Consultancy, and feel underloved by society. Of course this may be a force for good; part of the changing demographics of medical graduates that may force long overdue changes in our health system. Perhaps the more idealistic doctors leave themselves open to exploitation from healthcare managers, allowing even more corners to be cut, and ultimately their patients are the victims. But am I alone in seeing a risk here? Might this new hard-headedness become a new hard-heartedness? There is a tendency in medicine and medical education that has perhaps been ever-present, to downgrade the "art" of healing in favour of the "science" of medicine. Personally, it’s obvious that many of my fellow students regard subjects like Public Health and General Practice, with their emphasis on the overall picture of medical practice with at best indifference and often contempt, while seeing the technocratic, science based subjects as true medicine. “Every profession is a conspiracy against the public, every profession has a language of its own,” said the American novelist William Gaddis, and the specialised vocabulary that is popularly caricatured as “doctorese” derives from the world of medical science. Allow me to digress a little on this subject of the language used in medicine. It is an oft-repeated truism that there is a deluge of ever-increasing information; a figure of 2 million biomedical papers published per year is often cited. Yet how relevant is much of this information, and what are the motivations of those who produce it? The editor of the British Medical Journal once told a conference that “only 5 per cent of published papers reached minimum standards of scientific soundness and clinical relevance and in most journals the figure was less than 1 per cent.” In 1976, the Dublin physician J B Healy suggested that “we should for an experimental period of a year, declare a moratorium on the appending of authors’ names and of the names of hospitals to articles in medical journals. If the dissemination of information is the reason why papers are submitted for publication, there will be no falling-off in the numbers offered … But if far less material is offered to the journals, we shall have unmasked ourselves.” In other words, the culture of research-for-the-sake-of-research, of publish-or-perish, means that many papers are not written to be read but written to be cited, to become fodder for a CV. How is this damaging to medical practice? Aside from the obvious diversion of resources and effort from other areas, a culture that exalts personal ambition above all is entrenched. And the use of “scientific” language which can create an artificial mystique around the doctor, can thereby also create a new barrier between doctor and patient. In 1885 the surgeon William Marsden wrote the following straightforward sentence: “A hospital devoted to the treatment of cancerous disease seems to me to hold out the only prospect of progress in the treatment of the malady; an institution conducted by those who recognise in medicine and surgery but one art.” And in the year 2000 Dr. Michael O’Donnell “spread a month’s supply of journals across a table, opened them randomly, then used phrases plucked from the opening pages to encode Marsden’s original message." The sturdy High Victorian prose of Marsden is transformed into: “It would seem to the present author that only a specialist centre organised on the basis of concentrating its resources solely to address the treatment of the malignant disease process could offer a potential for realistic improvements in treatment outcome. Furthermore, such an institution would be a de facto resource centre under the direct line management of personnel sensitive to the fact that multifaceted disciplines of medicine and surgery are each essentially manifestations of the same entity.” Indeed. Although it would be naïve to believe that “journalese” is a new phenomenon, many journals seem to be written by people for whom speaking plainly isn’t an option; perhaps they are motivated by a nervous fear of not seeming “scientific” enough. If the medical profession is losing its eminence, than perhaps the rise of mystifying jargon represents a subconscious (or perhaps conscious) attempt to maintain some of medicine’s power and mystique. It is a near-cliché to define medical practice as a combination of the art of healing and the science of medicine. Many students (and doctors) would place the emphasis on the science term of the equation. But patients don’t exist as black-and-white illustrations of physiological phenomena. And if we are to communicate with our patients on a truly empathetic way, we have to realise that human experience is not like reducible to purely scientific phenomena. As John Fowles wrote "our fallacy lies in supposing that the limiting nature of scientific method corresponds to the nature of ordinary experience. Ordinary experience, from waking second to second, is in fact highly synthetic … made of a complexity of strands, past memories and present perceptions, times and places, private and public history, hopelessly beyond science's powers to analyse." And patients live their lives and come in to doctors’ surgeries enmeshed in this web of strands that we call life. If we are to practice patient-centred medicine, we must resist the temptation to transform the stories we hear into a means to an end – as Brian Hurwitz wrote in a recent article "the traditional medical view of the consultation is to see it as an opportunity to fashion a clinical case history … a story that begins with a succession of events or experiences relating to the patient, which then becomes progressively abstracted from the patient's control and the context of the original telling …[and] transformed by a medicotechnical vocabulary not likely to be understood by the patient. The patient tends to lose control of the story as the case history develops and becomes a tale that only someone else can tell, taking on a life of its own in staff rounds, case conferences, and the medical literature. Meanwhile, the patient as the person from whom the story originally arose becomes increasingly incidental to it, maintaining within it only the anonymous presence of a ghost." And it’s general practitioners, as always, who are primary health providers; primary meaning both the “first line of defence” but also the main practitioners most people will encounter. As Francis W. Peabody said in 1927 to the Harvard Medical School: “the essence of the practice of medicine is that it is an intensely personal matter, and one of the chief differences between private practice [by ‘private’ meaning general practice] and hospital practice is that the latter always tends to become impersonal. At first sight this may not appear to be a very vital point, but it is, as a matter of fact, the crux of the whole situation. The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.” It is a mark of Peabody’s wisdom that it wasn’t until after reading his address that I discovered it was written in 1927, for example he writes “the amazing progress of science in its relation to medicine during the last thirty years,” a sentence that anyone could utter today. This is an illustration that sometimes in medicine, like in many spheres, plus ca change, plus c’est la meme chose – every era sees itself as unique and pivotal, doctors will always be busy, medical science will always be shattering old dogma and producing new dogma to be shattered in turn, and the doctor-patient relationship will always be at the heart of medicine. That may be true, but equally there is no room for complacency – it would be ostrich-like behaviour of the worst order to imagine that we’ll all muddle through somehow, that all our problems are purely imaginary, or simply part of some sort of natural order. In the same speech as that quoted above, Peabody said “medicine is not a trade to be learned but a profession to be entered.” The most profound challenge for general practice in the coming years is to maintain the balance between the art of healing and the science of medicine, to resist the temptation to view patients in mechanistic terms, to retain the special character of the doctor-patient bond despite the pressures from both within and without the profession. The various challenges that I have listed above are all serious, and are all inter-related. They all both contribute to and result from a new mood in society – a general suspicion of the institutions of the past, a new assertiveness. All the above challenges can be seen as a opportunity for growth and renewal; the old paternalistic medical order has crumbled, so let us build a new one in partnership with our patients.