Will the patient pull through?

Hippocratic Oaths

February 4, 2005

With doctors disillusioned by government meddling and social shifts, David Weatherall asks how medicine can survive the state it's in

Over recent years, the morale of the medical profession has declined to such an extent that there are concerns about its ability to recruit sufficient doctors for the future. How can this be happening, particularly at a time when remarkable advances in the medical sciences are making it possible for doctors to offer better care than ever before?

No industrialised countries have been able to contain the spiralling costs of healthcare consequent on advances in medical research and increasing public expectation. Successive British governments have responded by continuously reorganising the National Health Service; it is impossible for anybody who has not worked in it to appreciate the effect that this constant disruption has had on patient care and the morale of health professionals. Those who entered medicine to care for patients found themselves constantly sidetracked to attend endless meetings in an attempt to deal with each new governmental pronouncement. Managers, recruited from commerce to improve efficiency, and still trying to make the transition from the world of the supermarket to that of the sick bed, were equally demoralised by constant changes in management structure and ever-increasing requirements to meet targets in the face of chronic underfunding. Mainly as the result of the dedication of its staff, some aspects of the NHS have undoubtedly improved, but its chronic instability has led to widespread disillusionment among those whose unselfish efforts have tried to improve its standards.

And medical practice has suffered from other pressures. As in the US, an increasingly consumer-led society with a cure-or-compensation mentality has led to defensive medical practice, with unnecessary investigation and treatment. As medicine has become more technological, and as the pace of patient throughput has risen, skills of communication and pastoral care have been compromised. Over-rigid regulations about the length of shift for young doctors and nurses have reduced the continuity of patient care and the quality of training. And media criticism of the profession, fanned by real or perceived instances of doctors' incompetence or worse, has steadily increased.

The signs that medicine is becoming less attractive as a career are already there, with falling numbers of male applicants for medical schools and widespread dissatisfaction among the newly qualified. Academic medicine, so vital for the future training of young doctors and the research on which medical advances depend, has suffered from both the chaotic state of the NHS and the lack of funding for universities; about one quarter of its senior posts remain unfilled.

Unlike many of its predecessors, Raymond Tallis's book on the ills of medicine is not so much a polemic as a balanced and highly personal search for the reasons why a profession that has achieved so much for the benefit of patients during his lifetime is now at such a low ebb. Although he believes that constant ill-planned revolution has been a major enemy of progress, he identifies many other causes. For example, the rise of alternative medicine reflects a denial of everything that has been achieved by scientific evidence-based medical practice over the past 50 years. And although he does not excuse medical errors, the trial by media that follows every event of this kind has become nothing less than a witch-hunt.

Discussing the recent vaccination debacle, Tallis highlights the dangers of a media that, through lack of scientific understanding and an obsession with eye-catching headlines, can potentiate and prolong the ill-effects of poor research, with disastrous results.

Tallis wonders whether medicine can survive as a profession. Consumerism - in patients who see the doctor as addressing their customer rights, and in self-protecting doctors who want a life but do not want to antagonise their customers - will turn the profession from a calling into a trade. And, if trends continue, a trade that is controlled entirely by government.

A Council for the Regulation of Healthcare Professionals, with the power to force changes in medicine's regulatory bodies including the General Medical Council, was established in 2003. The Government is taking over postgraduate education, and some politicians even suggest that the present pattern of undergraduate medical education, with the scientific breadth so vital for doctors and medical research workers of the future, would be cheaper if it were replaced by a first-aid course designed to produce a generation of barefoot doctors. Under these pressures, how can medicine continue to exist as a genuine vocation? As Onora O'Neill put it in her 2002 Reith lectures, "if we want a culture of public service, professionals and public servants alike must in the end be free to serve the public rather than their paymasters".

Tallis has already been accused of presenting the ills of modern medicine from the viewpoint of an inward-looking profession that has been singularly unsuccessful in evolving a level of self-regulation sufficient to protect its patients. There is some truth in this; the medical profession can be pompous, conservative, defensive, over-protective of its institutions, and at times slow to respond to the needs of a rapidly changing society. But although it may have been slow off the mark, it is responding to change while continually hampered by external interference, consumer pressure and, paradoxically, by the extraordinary pace of discovery in the biomedical sciences. The latter are unearthing the multi-layered complexity of the interactions between nature and nurture that underlie sickness, emphasising the even wider range of dedication, education, scientific sophistication and pastoral skills that will be required of doctors in the future; it will be disastrous if external forces, ignorant of these complexities, combine to destroy medicine as a true profession.

The only omission in Tallis's otherwise excellent analysis is a view of what can be done to improve the situation. Although he calls for strong leadership, it is not clear where this will come from. The profession, governed as it is by the British Medical Association and a proliferation of royal colleges and academies, can rarely speak with a single voice. Until it can, it will be easy prey for any government that wishes to control it.

And while it remains under the control of the day-to-day whims of politicians, with few thoughts beyond the next election, its endless battering by knee-jerk regulation will continue; the recent demise of the much-acclaimed (and expensive) NHS University must mark one of the shortest lifespans of any educational establishment on record.

Would any government have the courage and foresight to hand over the future development of healthcare in the NHS to a commission composed of a balanced mix of experts and consumers with the time to evolve the long-term policy, supported by scientifically based pilot studies, that is required for an evidence-based health service? While the public is willing to pay more taxes directed at health and education, the concept of earmarked funding of this type is anathema to the Treasury. These are fundamental issues; unless they are addressed, the genuine efforts that are being made by healthcare professionals to modernise and humanise medical practice may be to little avail.

Tallis believes that the medical sciences are capable of moving towards the ultimate aim of medicine: to make the human body less inhuman, regardless of age. But if trends towards dumbing down the profession to government-controlled, consumer-driven uniformity continue, it is unlikely that there will be doctors of the calibre to aspire to this goal on behalf of their patients, let alone with the imagination and independence of thought to ensure that it is achievable.

Sir David Weatherall is emeritus regius professor of medicine, Oxford University.

Hippocratic Oaths: Medicine and its Discontents

Author - Raymond Tallis
Publisher - Atlantic Books
Pages - 342
Price - £19.99
ISBN - 1 84354 126 2

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