Modern
medicine is being dehumanised. Doctors, other healthcare professionals and
patients alike feel it and are concerned. Something is missing. Something is
being lost.
Confidence
in the human abilities of the clinician is in decline. Even the clinicians’ own
confidence in their own human abilities is degrading. So they increasingly
delegate to the false certainty and security of science, technology and tests.
This
is as much a societal issue as a professional one. It is vicious cycle as
doctors conform to patients’ declining expectations of their human skills.
Human, clinical acumen is devalued in practice and the motivation to learn
those skills is lost. Acumen can no longer be trusted. Delegation increases.
Politicians,
administrators and bean counters accelerate the process, cutting the clinical
time to practice for cost cutting. Lawyers are turning practice into the second
rate minimum standard of routines, algorithms and the hard evidence of
defensive medicine. Every patient must be treated as standardised and average
according to the science and technology of physical pathology and disease
rather than complex, human individuals with particular psychosocial situations,
desires and needs.
Medicine
is being dehumanised from every angle. It is being dehumanised in reality.
This
conflict of interests and expectations can only be reconciled in one way. The
machines, technology and algorithms make all of the medical decisions and the
human clinician is in their service. The human doctor or other healthcare
professional becomes merely a human interface to the technology, firstly
providing data entry services and then breaking and softening any bad news that
the harsh tests and algorithms want delivering.
Or
does the doctor have the right to ignore the protocols and technology just
because the patient does not like what they say in terms of the diagnosis or
the treatment?
That
is the direction that basing medical practice on the lowest common denominator
of Win/Lose, Lose/Win sales would take the medical profession and healthcare
services. It is a situation in which everybody loses in the long term. Health
suffers in every way. The once noble medical profession would be disgraced.
The
endpoint is where society demands to know why it even needs doctors. Total
dehumanisation is the inevitable conclusion of degenerating clinical skills and
acumen. It is the consequence of medicine losing its human genius.
And
this goes against everything that is believed of how modern medicine could and
should be practiced. It is dangerously second rate medicine based on this
discredited and disproven public trust in the certainty and safety of science
and its technology in medicine. The evidence proves that they are neither
certain nor safe.
False
positives, false negatives and even complete errors are common and often
endemic to the nature of the test. They have consequences and patients suffer
and die as a result. Invasive and radiological investigations have significant
short and long term risks. Surgery and anaesthesia obviously carry significant
risks.
Over-medicalisation
is bad for health at every level.
Pharmaceuticals
are legally defined by their serious risks, side-effects and consequences. They
are not primary defined by their therapeutic effectiveness. It is a secondary
consideration. Many substances that are therapeutically effective according to
the evidence are legally classified as food stuffs, additives or supplements
because they are generally good for everybody and carry little in the way of
risks or side-effects, including in overdose.
The
list of therapeutically effective foods, additives and supplements is long and
it starts with the water, dietary fibre, protein, calories, vitamins and
minerals that are essential for the normal health of any life form to grow,
develop and survive. Garlic, red wine, glucosamine and omega-3 fatty acids are
amongst many examples of substances that have proven health benefits but that
do not need a doctor’s prescription because they are relatively risk and
side-effect free.
The
license of the doctor is defined as having the education and training required
to safely make individual, case by case, risk/benefit analyses for the use of
investigations and therapies that are potentially harmful including the use of
science and technology or anything that derives from them which requires a
doctor’s professional signature or hand. Their legally defined role in society
is the wise use and application of medical science and technology. They could
and should be the masters of that science and technology, not its servant.
The
dangers of over-medicalisation come into sharper focus with the modern
understanding and evidence of the primary importance of the patient’s life
style in maintaining their own health and preventing or managing diseases. The
scientific and technological model of health fragments the whole patient. It
fragments the complex human patient from their lives to leave what only the
medical technology can do for the patients. Power and responsibility have been
transferred. The patient has been disempowered. Hence, the monopolous use of
science and technology in healthcare leads to medical dependency and the sick
role.
Yet
internationally, modern doctors are becoming dependent and reliant on science
and technology. As they delegate decision making, they are losing confidence in
their own human acumen and judgement despite clinical wisdom and the very
definition of their license. The abilities and capabilities of the human
clinician are being devalued, deprioritised and neglected.
It is
happening in medical reality and practice because non-clinicians that only
value the science and technology, including academics, lawyers and patients,
and those intent on reducing the human cost of healthcare without understanding
the costs and consequences of doing so, are eroding the culture that created
the clinical arts. There is no time for the doctor to learn, practice or hone
those arts. Patients are fobbed off with these tests, technology and over-medicalisation.
A hollow veil of trust and satisfaction is created with this false paradigm
that the science and technology of modern medicine are both safe and certain.
Everybody suffers. Health suffers.
Of
course, the bean counters shoot themselves in the foot by forcing doctors to
order more expensive tests to create the illusion of good practice in lieu of
finding out what is wrong or not wrong with the patients using their skills and
acumen. Firstly, they need to see the patients a second time just for the
results. They need to sort out the false positives and false negatives. Then
the costs of the consequences and risks must be paid by the patient and the
medical system.
I am
put in mind of a TedX talk in which Dr Wen uses the case of one of her patients
who came to hospital after doing a bit too much in the garden. His body ached
including his chest so he was put into cardiac and respiratory protocols and
was investigated invasively for everything. He nearly died, including pneumonia
and major surgery for the aneurysm that was caused by the cardiac
catheterisation.
Yes,
clinical acumen is often just common sense but also having the confidence to
use it rather than delegating to the science, technology and tests. However, it
is becoming difficult in a medical world dominated by science and technology.
Dr
Wen also gives herself as an example. She suffered asthma as a child and
suffered not only pharmaceutical intervention but surgical intervention. An
anomalous part of her lung was removed with no positive result. Then one day
she was cured by a wise doctor who took the time to find out the cause of the
problem. The irritation of her lungs was nocturnal as a result of sleeping with
the window open. That window happened to be just above the extractor fan from
the kitchen of a restaurant which was contaminating her supposedly clean, fresh
air with smoke and fumes. The window was shut and she was cured.
These
are becoming major issues in modern healthcare. A professional backlash is
starting against the paradigm of science and technology in favour of a
healthier balance with human clinical acumen. The science and technology are
being put into their correct context. They are supposed to help medicine and
health by assisting and supporting the clinical skills rather than replacing
them.
Common
sense, the wise and sparing use of science and technology on human risk benefit
analyses and the importance of taking a full history of a patient’s life and thoroughly
examining them are being replaced, especially in the US and any country that
has followed their healthcare model and culture. These are just the basics of
good, human medical and health care that are being forgotten and major
literature and other media are now being produced to defend them particularly
where they are most lacking.
Those
are just the basics of human clinical abilities and skills that are being
defended. Little is mentioned of the highest reaches of clinical acumen and the
few that practiced to the fullness of their human potential.
Remember,
human clinical acumen was once all that a doctor had. Their five senses and
minds was all that they had to diagnose and treat. The possibility of reliance
on the modern science and technology of medicine is very recent.
This
created a generation of doctors who had learned to practice purely human
medicine at the outset of their career. As science and technology came along,
the best of them incorporated them into their clinical practice without
detracting from the human side of medicine. The best of them also experienced,
practiced and learned from the increasing importance of communication skills as
their importance in healthcare became more apparent during their careers.
Far
from all of the doctors of this generation achieved these highest standards of
health and care. These are the stories of the exceptional few.
There
was a spectrum. There were many very good to middling doctors but at the other
end of that spectrum were a few dangerously arrogant and incompetent doctors
who really did not care and got away with it at their patient’s expense. That
was unacceptable to modern medicine and its reputation. Science and technology
have been used to improve. They have provided a minimum standard of competence
and care.
The
problem is that the baby has been thrown out with the bathwater. The
insensitive process of standardisation with science and technology has
addressed the also-rans but at the same time denied medicine of its past
geniuses.
This
is the type of medicine of minimum acceptable standards that is being taught in
medical schools and the academic teaching centres. It is all that many modern
young doctors know or think possible. This is why they sit spellbound by
another perspective of clinical practice that relied on human genius with
science and technology playing second fiddle and a supportive role.
I was
extremely fortunate to have had a series of past masters of the clinical arts
as my mentors. I also learned from non-medical co-workers. Those arts were
never restricted to just doctors. It was an environment where the human arts of
medicine were valued and heeded as well as practiced.
The
subtleties of the human arts of medicine often outperformed the science and
technology in both their predictive accuracy and their specificity. Their human
impressions and thought had greater predictive value than a number or hard
radiographic image. These were truly geniuses of clinical intuition and
inspiration. It could even be said that they actively inspired their patients
to better health.
This
is what is being lost, as students and junior doctors are only taught the
mundane and routines of science, protocols and technology. The arts of medicine
are in the realm of the old school of truly great human doctors and other
clinical professionals whose wisdom is now retiring. Their experience is being
lost.
To
the mundane and closed mind of materialist science, which excludes anything beyond
scientific comprehension, it seems infeasible that a human being can
out-perceive a machine and out-think a computer algorithm. These are
inexplicable and unimaginable feats. They make no sense, perhaps because we know
so little scientifically about the human mind and brain as yet.
To
doctors indoctrinated in this scientific culture, such feats and deeds needed
to be seen to be believed possible. Rarely are they seen. Certainly they are no
longer the norm and the expectation of every clinician. They have become feats
of a gift of infeasible genius that cannot be reproduced. Or it is hoped that
they shall be reproduced by experience and come with time as they did in the
past. They should be a natural corollary of clinical experience as they were in
the past when many doctors and other clinicians truly mastered their clinical arts.
However the experience has changed.
The
culture and environment has changed. The training has changed. The medical
paradigms have changed. The societal context of beliefs, expectations and
demands that medicine must conform to has changed.
The
experience that allowed these genius clinical arts to develop over time is no
longer what it was. The old norms and expectations are no longer normal. What
was common once is now exceptional and incomprehensible genius never to be
repeated or learned.
The
environment that produced the highest levels of the clinical arts was like a
evolved ecosystem that has been interfered with by those that did not
understand its functioning or delicately interdependent nature. Nobody has
really understood it beyond the vagaries of experience. Often the magical act
of diagnostic intuition was put down to the words ‘I have seen it before’, that
patients with a certain, perhaps unusual or atypical condition, all look, act,
speak, feel or even smell the same. Something subtle but indescribable makes
the diagnosis and that diagnosis is certain so long as the doctor does not try
to think too much or rationalise what they know.
Perhaps
all that can be said is that there is a mysterious part of the human mind that
assimilates unconsciously the flood of sensory data to create a consistent
picture that matches another picture from the past. It is certainly not the
normal conscious mind and its linear, deductive thought processes. The subtlety
and mass of the non-verbal information is simply beyond it. To the linear mind
that can easily be expressed in rational words, this appears all but psychic.
The
mystery deepens in that these ‘seen it before’ diagnoses can be made for
conditions that have never been seen before. They are possible from getting a
deep understanding and feeling for a disease from the very best textbooks when
it fits into a perfected jigsaw of physiological, anatomical and pathological
knowledge. The patient’s history and how it will be expressed is known. On
examination, the hand becomes like a visual organ sensing and seeing how
pressure makes the anatomy react as if scanning.
Clinical
intuition is highly knowledge dependent. Knowledge is a part of the consistent
jigsaws that are being created in this mysterious, non-linear part of the mind.
To
the master of the clinical arts, the fragmented knowledge and understanding
that was learned in medical school was never an end in itself. It was the first
stage of a process in which it would all come together into a whole understanding
of humanity. Fragmented knowledge is always floating in the background waiting
to be put together into practice.
However,
that scientific knowledge is only a part of the picture. It is possible to make
a diagnosis before there is a single justifiable sign or symptom. The
technological tests have not yet changed. It looks like pre-cognition, the
ability to see the future from signs too subtle for the technology.
It
has to be seen to be believed. Such feats of diagnosis make no sense to those
who only believe in the science and technology rather than the potential of the
human clinician. The science and technology cannot think like this. They cannot
perceive like this. This is human potential that can only be practiced by the
human mind.
To
those that have only ever experienced linear, deductive rationality, this is
magic. It is supernatural. It is beyond them. It is superhuman to their
experience of human potential.
Actually,
it is formally hyper-rational. Formal logic rejects their linear deductive processes
as inferior to those that seek theories and diagnoses based on consistency with
the entirety of the available evidence without exclusion. This is the highest
standard of formal thought. It is seeing the whole picture.
It is
also a higher state of the objectivity that academic science proclaims. This
part of the mind appears able to extract the objective from the subjective and
fill in the gaps. It sees between the words to know what is being expressed. It
knows exactly which questions to ask to place all of the information in greater
context.
Nothing
can be hidden by words. Perhaps it is expressed by subconscious tone. Perhaps
it is simply a matter of fully comprehending the non-verbal communication that
is taking place.
Somewhere,
deep within every patient, they know what is really wrong with them. Good
nurses, even the best receptionists, see it. Often they feel it was a chill
down their spine. They know it but they cannot express it. They do not have the
words or concepts to express what they know. It is the intuitive doctor who has
that knowledge. It is the inspired doctor who has the knowledge and power to do
something about it.
Mothers
know when something is seriously wrong with their child but know what is wrong.
They do not have the words to explain it or concepts to express it. They can
know before there is anything to find. In the textbooks this is described with
undiagnostic vagueness as ‘how a child handles’. Attempts are made to
rationalise and explain but the only real explanation is mother’s intuition if
you know how to spot it. It is in her tone of voice and choice of words. There
is a tranquil, uncertain, confused terror about her that she cannot put into
words. She is concerned deeply but calm and compliant.
She
expresses her intuition through her eyes. Meningitis can be diagnosed instantly
on seeing a palpable silence in the mother’s eyes before the child even has a
temperature, let alone neck stiffness or a rash.
Experience
of doing this yourself is transformational especially when it saves a precious
young life.
No,
you cannot write that in a medical textbook or academic journal. It would
offend those less able who rely on the linear, deductive mind. Their mindset
demands the type of proof that can be measured by a machine rather than
evidence. However, anybody who has worked at the sharp end of healthcare knows
the importance of the silence. They know that silence foreshadows imminent
death at the scene of a major accident. They seek the silence since that is
where lives are saved.
Patients
know the presence of death and they know that they do not have the energy to
make a fuss. Their fear is contemplative and quiet as if their noisy ego dies
first.
The
silence affects on-lookers too. It can even affect those who are present but
that do not see. Its presence affects all intuitively. Counter-intuitively, it
does not cause panic. It clears minds. People intuitively quieten to efficiency
and know what to do. Lay people know whom to call because it is the best that
they can do under the circumstances.
And
in these extremis circumstances, clinical egos vanish. Everybody knows what to
do. Words are calm but deliberate. Experienced healthcare professionals
function as a well oiled machine.
The
core, ineffable mystery of the masters of the clinical arts is this silence.
This
is the mystery of abstract, philosophical psychology of human potential that is
beyond science. It is not considered in clinical psychology where the objective
is only to get the drowning patient’s head above water. This human potential is
usually only discussed in spiritual psychology and personal evolution.
To
understand the past masters of the clinical arts and how those arts were
learned and practiced requires that we delve into this abstract, philosophical
psychology of human potential. True intuition and inspiration come from the
silence of the superconscious, what Freud called the Super Ego.
Extending
and clarifying Freud’s developmental model into later life, we can see the past
masters of the clinical arts as having the wisdom of age. They conform
perfectly to the idealistic traditional stereotype of the wise elder, matriarch
or patriarch but empowered by knowledge.
For
those that have never known an ideal matriarch or patriarch in this world of
nuclear families and glorified youth, this person was a marvel. It was the
person who could be trusted absolutely to always say and do their very best for
you under all circumstances. They were secure enough in their position not to
do what was popular but what would produce the best outcome and they were not
frightened to tell you your part in a problem so that you could work on that
and resolve it rather than simply blaming the other. They were unbiased and
objective. At the same time, they were as caring as could be about their family
or community. They were selflessly caring.
This
seems entirely appropriate to medicine and the doctor-patient relationship. The
miracle of traditional medical education and training was to accelerate
personal development through the life stages to mature medical students and
junior doctors to this advanced life stage by the time they were thirty.
Medical
education and training was tough. It was done the brutal way without
understanding or explaining why it was so and had to be so. The cultural
purpose was to indoctrinate doctors to the deepest subconscious levels never think
of personal interests but to always go beyond the call of duty for every patient
regardless of hours or how the doctor felt.
This
subconscious indoctrination was so profound that it overcame their natural
physiology of stress and relaxation to allow them to function in otherwise
untenable conditions. It even overcame their hormones. It overcame the doctor’s
natural sexuality. They surrendered their gender to treat patients as a doctor
should treat their patients rather than the average man or woman off the
street. Psychologically, they did not have a sexual thought in their deeply
professional life.
Certainly,
all of the adolescent power games of sexuality had been erased from their
conscious and subconscious mind. Adolescent egoism and competitiveness had been
erased. They had been matured beyond such juvenile considerations. They would
not talk or act for hollow popularity, only for health outcomes.
This
calmed the chatter of the ego and allowed silence to be heard. It allowed
intuition and inspiration to be heard.
To
put this into perspective, the vocation of the monk was designed to achieve
this in isolation and through blind faith rather than real world knowledge.
After devoting their whole life to this path, they would perhaps reach this
ecstatic state once or twice in meditation or prayer and perceive its peace and
potential. They were mere observers of its peace and potential. The past masters
of the clinical arts lived and used that selfless silence and potential as the
source of genius in their everyday work.
This
was also the source of their confidence in decisively taking the impossibly
difficult decisions in the complexities of healthcare where every life and
death decision carries risks and side effects. Their self assurance came from
within. It came from the absolute knowledge of their objectivity and devotion
at a subconscious level. They were absolutely assured that the decision that
they took was cleansed of personal interest and selfish emotion. They had been
forcibly cleansed of that by practiced indoctrination of the highest medical
ethics.
Time
limited medicine imposed by administrators and bean counters is the antithesis
of absolute, uncompromising medical ethics. Enforcing defensive medicine is
enforcing defensive egoism. The deep selflessness that once existed is eroded
and lost. The silence of selflessness is lost.
Patients
sensed this selflessness. In part, it was expressed as an aura of physical
non-verbal communication that they recognised and trusted. However, it was also
an intangible presence of greatness that many describe on meeting others who
have lived a vocation to the highest level. Certainly it is missed in terms of
an aura-like presence that could be trusted absolutely.
This reassuring
presence appears to have acted as a placebo. Although the details of the
placebo effect are still shrouded in mystery, the basics of the physiology of
stress and relaxation are long known to have significant effects on healing,
recuperation and disease. These great doctors knew how to massage and entrance
relaxation and confidence in a smooth healing process in their patients.
Doctors
who have not grasped this subtle psychology of health can inadvertently act as
the opposite of a placebo. Rather than giving their patients confidence in
their ability to heal, they frighten them into ill health through their verbal
and non-verbal communication of their tension and fears.
In
the presence of the past master of the clinical arts, all goes smoothly. Most
patients run a smooth course. Any problems are predicted and pre-empted.
However,
this cannot fully rationalise the well known concept of the ‘lucky’ doctor that
dare not be spoken. It is well recognised in medicine that some doctors attract
tragedies of health whilst others are assured to have a quiet time of it.
Patients that they have never met do not get ill.
Lucky
patients!
I was
known to be one of those ‘lucky’ doctors. On call, my urgent work load was a
tenth of that of ‘unlucky’ doctors working on the same ward. The ‘unlucky’
doctors just attracted trouble.
So I
did an informal study teaching all of the doctors of a surgical unit and
introducing them to my state of mind; to calmly desire patients to be healthy
rather than to wish to be an all-saving hero. Emergency admissions fell by 90%.
The hospital lost the evidence accidentally on purpose for fear of funding cuts
or closure.
Now
that is a truly mysterious clinical art but many practicing clinicians quietly
accept its possibility. The evidence for the lucky doctor with luckier patients
is overwhelming. It is just a rational, scientific explanation for the
mechanism that is lacking.
That phenomenon
I can only record. I cannot explain it. Humanity obviously holds many mysteries
that are beyond present science. The past masters of the clinical arts were
masters of such human mysteries. They used those mysteries for the health of
their patients.
That
art is dying. It is being strangled by time limited and rational,
medico-legally defensible medicine. It is being replaced by the scientific and
mundane. Students and junior doctors have never even heard of it. The gene pool
of experience is thinning and will soon be extinct. Only science and technology
will remain.
The
human satisfaction of medicine and going beyond the call of duty in this noble
vocation is being lost. Consequently, the selfless human rewards of medicine
are missing as saving a life through individual genius is replaced by machines
and algorithms.
No
wonder the medical profession is burning out and demanding more societal,
egotistical rights. They are demanding normality where once they challenged the
limits of human potential.
It is
a vicious circle and self-perpetuating cycle.
Can
anything be done to break that cycle?
If
there is a solution to be found, it will come from understanding the bigger
picture of how the mundane and the subtle interact. Medicine is a complex,
evolved ecosystem with many interrelated and interdependent levels at play. All
these factors must be known and considered rather than fragmenting the greater
picture and context.
Non-clinicians
and society have interfered again with a complex ecosystem that they did not
understand. They had not experienced it. A new generation of doctors has not
experienced the traditional ecosystem of medicine as it used to be. They do not
appreciate the extraordinary, almost superhuman side of medicine, as created and
exemplified by the past masters of the clinical arts. The result is that they
have tampered with that delicately balanced ecosystem myopically using a
sledgehammer rather than treating it with respect.
It is
all about a lack of understanding of the cultural complexity of medicine beyond
the mundane and the statistics. Only that understanding can save the highest
levels of the clinical arts.
Senior
doctors who have tried to defend the old ways need the words and concepts to
defend them more effectively and explain the consequences of interfering with
the best traditions of medicine, its education and cultural training. They have
tried and succeeded in preserving and even institutionalising a few of the very
best practices of the past masters, such as the no blame culture of
multidisciplinary audit. However, this has only been possible for the more
mundane practices and the explicable end of the spectrum. The greatest esoteric
arts of the human clinician, the ones beyond science and technology, have been
lost.
A
central reason that the clinical arts are in decline is that their traditional education
and training was unacceptably brutal for modern societal sensibilities. The
hours that junior doctors worked were not safe in the context of competitive
role differentiation between doctors and nurses. Informally, it was understood that
the body of the nursing staff used to be the right hand of the consultant and
effectively outranked all junior and middle ranked doctors and provided a
second opinion on every decision. The unspoken cultural result of this was a
training in both selfless ethics and humility that allowed the exotic states of
mind that made the practice of the highest levels of clinical arts.
It
was this that allowed the silence to be heard. It quietened the chattering of
the ego.
If
only it had been understood how and why this harsh training created exceptional
human clinicians.
If it
can have been explained, perhaps some of the roughest edges can removed and
medical education made more palatable. Maybe it can also be made more effective
if everybody involved understands its purposes rather than resisting its
process because they feel abused.
Knowledge
of the real objectives provide the hope that those involved in the medical
education and training process will willingly, even enthusiastically
participate. Understanding can overcome resistance. Not only can that
understanding make the process far gentler but it can also make it far more
effective.
Maybe
there is some hope for the survival of the highest levels of the clinical arts.
There is some hope for the survival of the great contribution that the human
clinician can make to patient health by achieving their very highest potential.
It is only at that highest human potential that the human being outperforms the
machines and protocols and becomes their master rather than their servant.
It is the only healthy and productive future for humanity
in healthcare.
Please Comment!
(I am considering writing a book of experiences and cased studies based on this theme and would welcome any comments and guidance)