The complexities of medicine

The complexities of medicine

Hanging in the Tate Gallery in London is a painting by Sir Luke Fildes which is called The Doctor.

It shows a family doctor sitting pensively, with furrowed brow, and watching over a sick child lying on a makeshift bed in an impoverished household.

This was in Victorian times, when antibiotics had yet to be discovered.

There is little that the good doctor can do but watch and wait for that "crisis" to abate. The parents are in the background, half- shrouded in darkness. The distressed mother has her head buried in her arms on the table; on her shoulder rests the hand of the standing and tense father.

Amid this anxiety-wrought atmosphere is the balm of the doctor's concerned but calm authority.

It is said that Sir Luke painted this in 1887 following the death of his young son, when he had been greatly moved by the attending doctor's care and devotion.

Following the public exhibition of the painting, a grateful doctor wrote in the British Medical Journal in 1892: "What do we not owe to Mr

Fildes for showing the world the typical doctor, as we would like to be shown - an honest man and a gentleman, doing his best to relieve suffering? A library of books in our honour would not do what this picture has done and will do for the medical profession in making the hearts of our fellow man warm to us with confidence and affection."

For the longest time, doctors had that place in the hearts of the public. They were revered, admired and envied. Scientific advances have saved millions of lives and life expectancy has increased significantly in the last century - all of which have further enhanced the status of doctors.

But in more recent times, there has been a shift in the public perception of the medical profession.

More than a century after that enthusiastic letter in the British Medical Journal, a latter-day doctor writing in the same journal in 2010 observed that despite the great advances of modern medicine, the "high watermark of public perception represented by The Doctor has long passed".

In July this year, the journal noted gloomily that over the past two decades, the British media's portrayal of doctors has "gradually shifted from appreciation and respect towards antipathy and resentment".

There have been more and more commentaries on the flaws and shortcomings of the medical profession - raising questions of competence, moral standing and authority. To a large extent, this has been engendered by stories in the press and social media of instances of hubris, mendacity and venality among members of this profession.

The year 2014 was a sort of Annus horribilis for my own medical profession. Littered throughout the year were highly publicised accounts, including in Singapore, of the various misdemeanours of certain doctors and conflicts within the profession.

What caused this shift in the public perception of doctors?

The heroic doctor myth

It is certainly more than just the unfortunate focus on the few proverbial black sheep who had strayed from the straight and narrow. As in any profession, there will always be a few of these.

Instead, one reason for the shift in views is ironically the unintended consequence of stories that raise expectations of the power and glory of modern medicine.

The surgeon and writer Atul Gawande was invited to deliver the 2014 Reith lectures, an annual series of lectures commissioned by the BBC that provides a platform for a leading thinker of the time.

Gawande started one of his lectures with a riveting clinical tale of a three-year-old girl who fell through the ice of a frozen pond in a small town in Austria. In the dark depths of the icy cold water, they could not find her for 30 minutes. When she was finally brought to surface, she had by then neither respiration nor pulse, and her pupils were fixed and dilated.

Cardiopulmonary resuscitation was started and she was flown by helicopter to the nearest hospital. She was hooked to a machine to warm her blood which got her heart beating again. She was then attached to an artificial lung to get oxygen around to the organs of her body while the medical team sucked out the pond water and debris from her lungs before connecting her to a ventilator.

The team then worked systematically and with consummate skill on very part of her body to get each organ and system back on track, including inserting a probe into the recess of her brain to measure the pressure of her swollen brain.

The little girl lay in a coma for a week and then woke up. Two weeks later, she was discharged but needed intense rehabilitation. Two years later, when she was reassessed, there were no deficits and she was like any other five-year-old girl.

It was spine-tingling to listen to this account: It was heroic and an example of modern medicine at its best.

It also made me wonder if we have become victims of our own successes - giving doctors a misplaced sense of omnipotence and instilling unrealistic expectations among the public.

Patients have come to expect that lives can always be prolonged if not saved, that pain and suffering would be invariably alleviated if not abolished, and that everything should work like clockwork.

The point that Gawande wanted to make with that case was that medicine is extraordinarily complex and though tremendous discoveries have been made, it's extremely complex to deliver on them. As he remarked: "We have 13 different organ systems and, at the latest count, we've identified more than 60,000 ways that they can go awry."

Most of the time, doctors do deliver - which is why when things don't turn out as expected, people get baffled and upset. Doctors might then feel guilty and ashamed; patients and families disappointed, disgruntled and angry.

This is compounded by the high cost of medical treatment which is perceived by patients and the public to be largely due to the high charges levied by doctors for their services. Medicine is supposed to be a noble profession and the mercenary pursuit of money is anathema to it.

Doctor says, patient challenges

Another factor accounting for a shift in views towards doctors is the loss of that absolute Aesculapian authority that doctors used to have over patients, enshrined in the ideal of Asecupalius as the mythological god of medicine and healing, whose rod of a snake-entwined staff remains a symbol of medicine.

In 1984, a book called The Silent World Of Doctor And Patient was published. The author, Jay Katz, a Yale physician, attacked the traditional top-down, "doctor says/patient does" relationship and argued with vivid case studies that it had resulted in poor care and outcomes. This influential book heralded the movement of health-care consumerism that stressed patient empowerment and autonomy as well as shared decision-making.

To top it all, the Internet has broken the professional monopoly on medical knowledge, and it has also enabled patients to compare (and criticise) doctors and air their grievances.

Doctors have to accept that patients and their families are today better informed, more critical, more resourceful and more demanding, just as we have to accept that doctors' work will continue to be scrutinised and our misdeeds reported by the media.

"The world is chaotic, disorganised and vexing, and medicine is nowhere spared that reality," Gawande once wrote. "To complicate matters, we in medicine are also human ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two. It is to live a life of responsibility."

Most doctors are responsible and conscientious but the practice of medicine is fraught with uncertainty and complexity. We need to realise our limitations and fallibility - but just as important, we need our patients and the public to know that as well.

stopinion@sph.com.sg

The writer is the vice-chairman, medical board (research), at the Institute of Mental Health.


This article was first published on December 27, 2014.
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