Much of medical training is based on understanding the disease. But, more often than not, in a primary care setting, the doctor deals with illnesses rather than diseases. And understanding illness is not quite the same as understanding the disease. Indeed, illness includes the feelings of regret, guilt, fear, betrayal, loneliness, and all the other emotions that turn the same disease into different illnesses in different people.
Donald Irvine puts it quite eloquently in a 2003 article published in British Medical Journal, “Success relies on winning hearts and minds”, “Evidence is abundant that the public want doctors who are technically competent; give them the best possible clinical outcome; are as safe as possible; are kind, courteous, and respectful; and involve them in decisions about their care.”
But I also feel something missing here. The question about how it should be done, doesn’t quite tell us what should be done? The difference could appear superficial yet its implications profound.
Back in 1890s, the illustrious James Mackenzie captured the world’s attention with his many path-breaking contributions to cardiology. The one that I remember clearly from college was the description of the ‘irregularly irregular heart beat’. Mackenzie’s biography ‘The Beloved Physician.’ is one book I keep coming back to. For it charts the travails of a petty physician assistant who moved on to become the patriarch of cardiology…. and Mackenzie was beloved because he cared. Quite true that the doctors in Mackenzie’s time were unable to make most of the diagnoses of the conditions that their patients were experiencing, simply because most of these conditions had not yet been discovered. The same could very well be applying to us, although we don’t realize it just yet.
It wont be a surprise that medical journals in 30 years could well be full of conditions that nobody has ever heard of, but exist today undiscovered. Doctors in the past had virtually no effective investigation or drugs. Nonetheless, the people and populations they served believed they were hugely valuable – a fascinating paradox. We do have powerful drugs, and clever diagnoses. But maybe the part of the consultation that ultimately matters the most to many patients is the part that is most downplayed in the search for scientific truths and recordable data.
Quoted below verbatim from the paper “The placebo effect” by Watkins P (2003) in the journal Clinical Medicine:
“The good consultation should always leave a patient with an increase in self-esteem and perhaps some alleviation of their symptoms as well. Our forebears knew that their clinical skill in the consultation was paramount, given that their medications were often ineffective and functioned solely as placebos. The skillful consultation itself often has a placebo effect, depending on the bedside manner.’ (Watkins P, 2003).
I tend to think that today we might just be creating a form of medical practice that will not permit the placebo effect to work. We only realize this when research shows us that many of the treatments we are using are ineffective. People probably trust us because of all those consultations where nothing much seemed to happen. Irrespective of what we did therapeutically, they got better.
And here’s Mackenzie again quoted from his biography:
‘I was not long engaged in my new sphere when I realized I was unable to recognize the ailments in the great majority of my patients. For some years I went blundering on, gradually falling into a routine, giving some drug that seemed to work favorably on the patient, till I became dissatisfied with my work and resolved to try and improve my knowledge by more careful observation.’ (Macnair, 1926; page 52)
Could it be possible that what he appears to have recognized then is something we still recognize today: the quite extraordinary mismatch between the medical textbooks and the ways in which our patients present to us. Apparently, it was his attempt at gaining some clarity into his professional life, that led Mackenzie on the track that was to become his destiny. From a GP he turned into a GP with a special interest (whatever that means), and his special interest was triggered by the death from heart failure of a young woman in childbirth…… and his special interest was what we refer to as cardiology.
To be continued…..