Take a dose of humility

Second Opinion
August 1, 2003

David Weatherall examines the patient chart for global healthcare.

Medicine's finest hour is the dawn of its dilemmas. With mission accomplished its triumphs are dissolving in disorientation." These prophetic words were written in 1997 not by an ambitious shadow health minister but by the historian Roy Porter in his pessimistic summing-up of the current medical scene at the end of The Greatest Benefit to Mankind, a panoramic account of medical history.

Worse was to follow. James Le Fanu, in his gloomy book The Rise and Fall of Modern Medicine, claimed that, after the remarkable advances in clinical research and care in the second half of the 20th century, medical progress had ground to a halt. Its two great hopes - epidemiology and the fruits of the genome era - were non-events. Epidemiology was simply confusing us, and the genetic approach to medical research was turning out to be a chapter of unfulfilled promises.

Those who have followed media coverage of the medical scene in the new millennium may well feel that Porter, Le Fanu and other commentators who have written in a similar vein have not been far off the mark in their prognostications. The media abound with regular accounts of doctors'

incompetence or inhumanity; stories of babies' organs being retained in children's hospitals without parents' knowledge; continuous and disruptive government attempts to stop the dissolution of the National Health Service; spiralling medical litigation costs; and - for good measure - the case of a medical serial killer, GP Harold Shipman.

Not so newsworthy, but of far more global importance, are conditions in the poor countries of the world. Their plight is characterised by utter poverty and dysfunctional healthcare services; the decimation of large populations by Aids; the recrudescence of malaria and tuberculosis as major killers; and the appalling child mortality rates due to infectious diseases, many of which are preventable.

Even those who attest to the view that only bad news is newsworthy must, in the light of all this criticism, feel uneasy about the current medical scene. But how bad is it? In Second Opinion, Richard Horton, editor of The Lancet, has attempted to answer this question in a series of extended essays covering many of these problems. At first sight, it appears that he has chosen to address an odd collection of topics: an investigation of the adulation of William Osler; an inquiry into the activities of the Royal Society and the World Health Organisation, a re-examination of the thalidomide scandal; and the moral dyslexia of surgeons, to name a few. But these reflect Horton's day-to-day skirmishes as editor of The Lancet.

Important themes recur throughout the essays, notably the decline of good doctoring, the uneasy relationship between medical practice and commerce and, in particular, the developed world's neglect of the plight of sick people in developing countries.

Horton begins with a long piece on the current diseases of medicine.

Covering some well-trodden ground, he places the blame for many deficiencies of modern doctors on the tension between the science and practice of medicine. He believes that, in reflecting their training, doctors neglect patients' histories, relying instead on the greater certainties of the laboratory for diagnosis and on "evidence-based" medicine for treatment, despite its emphasis on large populations rather than individuals.

Yet paradoxically Horton is dismissive of the art of clinical practice, finding the concept backward-looking and at variance with contemporary issues in medicine. If by "art" he means the ability to converse and empathise with sick people, combined with that part-taught, part-instinctive ability to spot the pathological wood among the infinitely variable trees of human illness, he is surely wrong. The application of molecular and cell biology to the study of human disease has emphasised that it is a multilayered process of enormous complexity, reflecting as it does our genetic make-up, our diverse and rapidly changing environments, and the ill-understood biology of ageing.

In addition, there are the many different ways that individuals react to disease, their broad social and religious backgrounds, and the increasing belief on the part of society that disease and death are not acceptable facets of the human condition. However much we learn about the mechanisms of disease and how to prevent or reverse it, there will always be a vital role for that indefinable facility - the "art" of doctoring. Indeed, Horton's account of current medical science underplays the major changes that have been made in medical education in recent years, such as the emphasis on communication skills, the art of listening, and on taking a more holistic approach to patient care. If we are failing, it is in preparing our doctors to appreciate or cope with the many-layered complexities of sick people. Horton rightly asks for more humility on the part of doctors - an emphasis in their education on how little we know may be a good place to start.

Overall, however, this long essay offers a much more balanced view of the deficiencies and hopes of modern medical science, particularly genomics and the role of epidemiology and public health, than a lot of contemporary writing on the topic. And Horton hits the nail on the head when he raises the central issue of the lack of time doctors spend with patients. Surely this is the reason for much of the bad press about the medical profession.

One of my colleagues was recently admitted to hospital with an abdominal emergency. When I inquired about the standard of care, he told me that one young doctor stood out from all the others in terms of the time she spent talking to him, examining him and, in particular, going through all the diagnostic and therapeutic options with great sensitivity. A tactful inquiry revealed that she was a medical student, presumably the only member of the team who had the time to function as a complete doctor.

Horton suggests that a research study is needed to assess the benefit of time spent with patients. But surely this has already been done - it must be one of the major reasons for the massive migration of patients from conventional to alternative medicine. But given the staffing levels in the NHS and the time staff spend trying to meet the demands of governmental reorganisations, where can this extra time come from?

In short, there seems little ground for pessimism on the future of medical research. There has always been a long lead time between major advances in the laboratory and their application in the field. To improve long-term prospects, molecular sciences need to link forces with epidemiology and public health. The real problem lies in the delivery of healthcare, even in developed countries, none of which has found a way to deal with spiralling costs appropriate to medical developments and public expectations.

The situation is unlikely to improve until activities such as health are removed from day-to-day politics. Politicians have a vital role in deciding how much of the nation's budget is spent on health, but how it is spent should be removed from the political arena and devolved to a body with a broad-based membership of experts and consumers who can take a long-term view. Changes should be assessed coolly after adequate pilot studies rather than the quick-fix mentality that typifies the current healthcare scene.

However, a great strength of many of the essays in the book, and, incidentally, of The Lancet under Horton's leadership, is their preoccupation with global health issues. Horton has taken the trouble to spend time in developing countries and with major international healthcare agencies. Although he does not provide answers to many of the problems faced by developing countries, his essays go a long way to defining them more clearly and to pointing out the deficiencies of governments, non-governmental organisations and the medical profession in the rich countries in trying to correct health inequalities between North and South.

Along the way, at least to this reviewer, he paints an accurate picture of the tensions between the commercial aspirations of some of the large pharmaceutical companies, the World Trade Organisation and the international health agencies that are trying to improve access to medicines for the poorer populations of the world.

Horton concludes that it is vital for doctors in richer countries to become more aware of the health problems in developing countries. But he could have gone further. A great deal can be done at the level of individual doctors, universities and governmental and charitable funding bodies of rich countries to improve global healthcare. There are already examples of the benefits of North-South interactions at this level, although these are still few and far between. A complete change of emphasis in medical and science education is required to help the next generation of doctors and scientists to become much more aware of the international aspects of disease. During their training years, students should spend time in developing countries; universities should develop long-term clinical, teaching and research programmes with partners in the developing world; and there should be a constant movement of students and young graduates in both directions. Some imaginative ways in which this might be funded have been suggested and, given the will on the part of our universities and governments, such a change of direction is surely feasible.

As a start towards this more global orientation in medicine and science in rich countries, those responsible for teaching these subjects in our universities would do well to read Horton's excellent essays. If they find things to irritate them and with which they disagree, so much the better.

The development of a debate on the globalisation of medical research and practice is long overdue on both sides of the Atlantic. Similarly, general readers who wonder what on earth is the matter with modern medicine will find much both to reassure and disturb them in these accessible stories, which may not add relish to their next visit to the GP but will certainly give them a better appreciation of what makes modern doctors tick.

Sir David Weatherall was formerly regius professor of medicine, University of Oxford.

Second Opinion: Doctors, Diseases and Decisions in Modern Medicine

Author - Richard Horton
ISBN - 1 860 587 5
Publisher - Granta
Price - £17.99
Pages - 582

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