Abstract
Everybody says that proper medicine is holistic medicine. And surely that is right. A proper doctor doesn't just treat a problem; he treats a person who happens to have a problem. He treats a mind-body-spirit unity. In this respect, doctors are unique among professionals. An accountant discharges his responsibility by getting the bottom line of the balance sheet right. A lawyer discharges his obligation by writing a legally impeccable opinion. But a doctor who treats a diseased kidney rather than the possessor of the diseased kidney is a bad doctor. A good nephrologist is a first-rate GP who knows a lot about kidneys.
There is nothing new about these observations. The doctor–patient relationship has long been acknowledged to be as crucial a part of the diagnostic and therapeutic process as auscultation and antibiotics. Bad relationships do actual harm – hence doctors have for centuries been rightly censured for inappropriate sexual relationships with their patients. And would anyone seriously doubt that patients who trust their doctors are likely to do better than those who don't? If the placebo effect works for a sugar pill, surely it is likely to work even more effectively for an apparently sympathetic doctor. If that's right, isn't a genuinely sympathetic doctor likely to be even more diagnostically and therapeutically potent than one who apes sympathy? Everything we know about alternative medicine, witch-doctoring, sheer quackery and the healing power of a listening barmaid indicates that whole people are likely to be treated best by doctors who treat them as whole.
Why is this? The ultimate answer probably lies deep in a metaphysical labyrinth, and I am no Theseus. But it is rather obvious that patients have contexts, and the contexts matter and need to be understood. Often the whole family of a young amputee will need to be treated. Still more so the family of a terminally-ill cancer patient. The doctor is necessarily physician to the whole nexus in which his patient lives and dies. For legal purposes he might have a duty only to his patient, but in order properly to discharge that duty, his tentacles of enquiry and understanding have to reach far and wide. Again, rather obviously, it is very often bad medicine to treat only the symptoms of a disease. A good doctor will therefore acknowledge the simple fact that disease is often a symptom of something else. He will track the problem to its source and get a better, more widely repercussive result.
This sounds scarily mystical. I hope it is exhilaratingly mystical. It makes every doctor a psychoanalyst, a shaman, a detective, a priest and a friend – which is all a long-winded way of saying that it requires every doctor to be a whole human being. That's a high, romantic, but essential calling. Only whole human beings can treat whole human beings.
Now that's a problem. Being a whole human being is a big thing to demand of anyone, but it is a particularly big thing to demand of doctors, whose training is so concentrated, who have to know so much about so much, and whose time per patient is so appallingly limited.
I have a nasty suspicion that doctors, for whom wholeness is so uniquely important, are almost uniquely unwhole. I would like to think that this is a remediable consequence of their training. The medical curriculum necessarily requires lots of mind-numbing, personality-truncating rote learning. I shudder when I remember the crushing littlenesses showered on me by the Medical Sciences Tripos at Cambridge.
But perhaps, too, the profession attracts nerds, or encourages them to rise to govern. Memory unpleasantly insists that, even when the study was controlled for workload, the Cambridge medics (with many honourable exceptions) were objectively more grey than the English undergraduates. And that's all the wrong way round: the medics' ambit was the whole of human existence: the English students merely had to understand a few books from Beowulf to Virginia Woolf.
Whatever the reason, it is disastrous.
Some disagree. In his 2006 article in the BMJ, Julian Savulescu (himself one of the most liberally educated of doctors), asserted that a doctor's personal philosophy should be left at the operating theatre door like his outdoor shoes. 1 And for essentially the same reason – namely that it would contaminate dangerously the practically and philosophically pure business of medicine. For him, doctors are technicians: clever pairs of hands; walking protocols. And if they don't like that, they shouldn't be doctors.
His article, as he no doubt intended, generated an almighty storm. Amid all the outraged expressions of professional pride and the overstated concerns about the pruning of religious liberties, there was one dominant theme: Savulescu is wrong: medicine is not a practically or philosophically pure business because, if it is done properly, it is all about individuals who are not practically or philosophically pure. Medicine is not a book of protocols because humans, whether ill or well, are infinitely various.
How can doctors be made whole? How can they be equipped to deal effectively with the complex bundles of contradictions they call their patients?
In the last few years medical ethics and communication skills have increasingly been recognized as essential parts of the undergraduate medical curriculum. That is laudable and significant. But it is not enough. And it has its dangers. To recognize ‘ethics’ as a distinct, examinable academic subject might imply that there is a time when one ‘does’ ethics, and accordingly a time when one does not; that ethics exist in a box, to be carried around on the ward like a stethoscope or the Oxford Handbook of Clinical Medicine, and whipped out when needed. It might imply that ethics are not something intrinsic to everything one does as a doctor (and therefore, since there are, or should be, no 9-to-5 doctors, as a human being too). Teaching ethics and communication skills to people who don't know what or why they believe is like teaching oncology to someone who hasn't endured the grind of the preclinical sciences. The student might be very good at listing the signs and symptoms and reciting the treatment protocols, but they would be dangerous in practice because they would not understand why anything was happening and would not be able to tailor their practice to new circumstances. Undergraduate ethics teaching is not the answer.
Some non-medical teaching at undergraduate level would undoubtedly be helpful. Yes, it is a crowded course, but if the only way to seed tired, bored brains with Shakespeare or Mozart is to sacrifice a detailed and utterly irrelevant knowledge of the origin and insertion of abductor pollicis longus (all of which will be forgotten, re-learned and re-examined in colossal detail for the FRCS, where it is important), for goodness' sake do it.
Perhaps more could be done at the stage of selecting medical students. I am sure that the medical schools would say that they are doing this already: that all the serious candidates have four A grades at A level, and that the determining criterion is therefore a distinguished career on the stage, record-breaking athletics or a dazzling presence at interview. No doubt they are right. But perhaps the problem is in getting the right candidates to apply. What is really needed is for medicine to be seen as the King of the Humanities. The people who should be applying are those who want to understand human beings, and want to understand the Krebs' Cycle only because it is a tiny but important part of the human cocktail. At the moment many who apply want to understand the Krebs' Cycle, full stop. Or, worse, see the Krebs' Cycle mainly as a money or status generating machine. Medicine is a self-perpetuating nerd-ocracy.
Medical humanities is another discipline in the ascendant. But until now it has been the province of a beleaguered minority of tweedy, Proust-reading doctors and some earnest English graduates in kaftans whose uncles were GPs. It needs to become medicine itself, receiving grovelling tribute from the secondary disciplines such as oncology, neurology and cardiology.
Re-accreditation should demand not that doctors snore their way through a day of drug-company sponsored propaganda on new NSAIDs, but that they attend their local book club. Judges, who have said for decades that patients' best interests are wider than their ‘medical best interests’, should insist that the clinicians who routinely conduct those best interests determinations can identify the non-medical grounds for their conclusions. A doctor who does nothing but rheumatology and golf should be sneered at.
This is not a plea for a sniffily high-brow medical salon culture. It is not an assertion that doctors who listen to Verdi at Glyndebourne are better people than those who listen to Chris Moyles over their cornflakes. But it is a tentative suggestion that since Verdi was and Chris Moyles is a member of the human race, knowledge of both of them is an index (nothing more), that the doctor is keeping up appropriately with the subject matter of his profession. ‘I do not know a better training for a writer than to spend some years in the medical profession’, wrote Somerset Maugham. The converse is true: there are few better ways for a doctor to appreciate the scope of his own subject than to keep the company of the writers, musicians, artists and philosophers who, over the millennia, have struggled to understand what human beings are and what makes them tick. True evidence-based medicine involves consideration of all the available evidence about human beings and their place in the universe.
I have a recurring fantasy. I am sitting in a GMC Fitness to Practise hearing. The charges are being read over to the respondent, who is a Harley Street surgeon of great eminence. I cannot hear them all, but I catch some delicious fragments: ‘Your CPD was inadequate. You failed to keep sufficiently abreast of the literature relevant to the practice of medicine. In particular the Performance Assessors found your knowledge of Aristotle, rap culture, the Florentine Quattrocento and Ghanaian geography to be deficient … In treating only the body of X, a mind-body-spirit unity, you dangerously neglected at least two-thirds of your patient … Despite warnings from the GMC you failed to get a life. And by reason of the matters aforesaid, your fitness to practise is impaired.’
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