My response (that was moderated for hours and left me assuming it had been refused) to an excellent provocative blog by Richard Smith, Time to get rid of health professionals?
What patients want from their doctor are explanations for their suffering. As described by the medical historian Henry Sigerist, the demands on the ‘medicine man or woman’ have changed little in the last 2000 years even though we health professionals have. We have un-bunged the pill-bottle and released the genie of modern medicine and done our damndest to separate the modern empirical doctor from our ancient ancestors who were magicians and priests, but the failure of science to dent the ‘alternative health industry’ is just one example of the failure of modern medicine to provide an adequate explanation for much of human suffering.
In many instances, people choose the interpretation and hence the ‘healer’ that fits with their belief system. Richard’s question, posed on Twitter was, “What would a world without health professionals look like?” It would be a world full of health non-professionals who would step in to provide alternative explanations for human suffering. Clearly the role of science and evidence based medicine is invaluable and has saved countless lives, but it only deals with a tiny part of our patients’ needs. History tells us what a world without health professionals would look like: the ancient ‘medicine man or woman’ was far more than the modern equivalent, being an intermediary between the spirit world and the patient, or God’s representative, exorcist, adjudicator, protector of the tribe and more. Unlike the modern doctor, they would never attempt to reassure their patients’ that their symptoms could not be explained and hence were nothing serious.
The fifty year old woman I look after who has spent most of the last 30 years under the care of gastroenterologists, surgeons, gynaecologists and pain specialists confessed last week that she blames all of her symptoms on her forced marriage at the age of thirteen. Another woman who has puzzled head and neck specialists for decades says she knows she won’t get better because is being punished by God for an ‘indescretion’ over 50 years ago, unresolved because her husband died suddenly just when she had resolved to tell him.
Working in general practice today, whilst not on the whole cognisant of our ancient heritage, it is clear that we are the descendents of our mystical forebears, not that we have trained this way, nor that we choose to be, but it’s what our patients demand of us. It is what I meant in the previous post, what is a GPs role today? ‘we are what our patients’ make us’.
As brilliantly articulated in Iona Health’s recent Haveian Oration, the most significant part of a GPs job is to manage the interface between suffering -what the patient presents with- and illness or disease. Only rarely is it necessary to refer patients to a hospital specialist for medical management. Our job, far more than diagnosing disease, is diagnosing ‘non-disease’, in other words, helping patients to cope with illness and suffering without imposing a medical diagnosis.
Even for patients with established disease such as diabetes or heart failure, most presenting symptoms are ‘non-disease’, real, somatic symptoms (not imaginary) but symptoms that cannot be explained in biological/ medical terms. The proportions of people who present to doctors with symptoms that defy medical definition is surprisingly consistent be it the centre of a modern metropolis or in a village in North West Afghanistan or Nepal (both are places I have worked).
Looking after people who present this way is the most time-consuming, challenging and valuable part of our work. Protecting patients from unnecessary medical intervention and reducing medical costs may be the best we can do, but it’s clearly not enough for patients who are rarely reassured by our lack of explanation and are rightly suspicious of our position as healthcare rationers.
What is also clear is that it is inadequate to dichotemise symptoms into those that science can explain and those that it cannot. A more rounded medical education can help, but the best education comes from listening to our patients stories.
This work cannot be measured in terms of productivity; there is no measurable difference to the patient, no data gathered, no drugs prescribed, blood results generated, biometric data tweaked. It is invisible work and the reforms threaten this by turning patients and their care into commodities which require value adding at every interaction.
The future is one in which the business of managing disease may, as Richard suggests be increasingly removed from health professionals, but disease management is only a part of what we do.
The future will, I hope, be one in which human relationships are central, and one in which the desire for meaning is taken seriously. And the GP will be much closer to his or her ancient ancestors than the scientific doctor Sigerist envisaged or Richard Smith believes us to be.
Does The US Health System Really Need Doctors?
The Therapeutic Relationship. Kings Fund report by Iona Heath and Trisha Greenhalgh
Why would there be no measurable difference to the patient? If my mind were more at ease that might generate measurable differences.
When you have a chronic, genetic condition, you question every twinge/ache/unexpected body change. You wonder if your loose bowels are diverticulitis, if your tiredness is anaemia, if your headache is an aneurysm, if your broken heart is CVD.
Then you seek the juju man or woman, the GP or homeopath, according to preference.
Chronic disease is like a homunculus, grossly distorting the average course of life, illness and death.
When someone with a chronic disease and Long Term Condition (LTC) presents with symptoms at their GP, some may be as a result of their LTC, and some may be exacerbated by their acute sensitivity to their condition. How then to differentiate between the real and the non-biological?
Reblogged this on Toby Hillman's Blog.
Your comments relating to narrative are so pertinent.I left General Practice for a number of reasons,one of the most important being the loss of recognition of the individuality of the patient with consequent reduction in respect for their beliefs.Illness behaviour cannot be understood without providing acceptance without criticism for each patient’s unique experience of life.
I’m a huge fan of yours, but I suspect that what you are really saying is that medical science is still very far from perfect. The fact that little can be done about colds are low back pain means that consolation is all that can be done. Analgesics just don’t work very well. The thing that worries me is that so often these failures are not admitted frankly. If you listen to a meeting of pain physicians, you come away with the inpression that the problem is solved. It isn’t. And almost all problems related to the CNS are unsolved,
I don’t think that anyone is to blame for the failures. Serious research has been going on for barely 100 years, and it has turned out to be exceedingly complicated. This doesn’t mean that medicine isn’t scientific, just that not nearly enough science is known yet. I would be fascinating to know whether viruses, and back pain, are still huge problems in another 100 years. I have no idea.
The other relevant point is that it’s often quite possible to test how well social intervenions work, though it’s rarely done properly.
A doctor may have to be something of a shaman now, but that is merely a reflection of our ignorance, not a desirable end.
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