Intended for healthcare professionals

Editor's Choice

Medicine's complexity: exhausting or inspiring?

BMJ 2004; 328 doi: (Published 09 January 2004) Cite this as: BMJ 2004;328:0-f
  1. Richard Smith, editor (rsmith{at}

    The central fantasy of medicine is seductive. The patient who has suddenly become desperately sick needs the help of you, the lone doctor. Listening with the intelligence and attention of Sherlock Holmes you pick up an elusive clue and form a diagnosis. Remembering some recondite piece of anatomy, you make an examination that shows you're on the right track. Your examination through a microscope of a speck of urine confirms your highly unusual diagnosis. An injection, and the patient is cured. She smiles beautifully, thanks you profusely, and the next day leaves you a brace of pheasant, a bottle of your favourite whisky, and an invitation to her island retreat in the Caribbean.

    The BMJ—perhaps sadly—deals in messy, complex reality, which is ultimately, I suggest from my ivory tower, much more interesting. Consider the patient who wants a sickness certificate. He looks fine to you—in fact a lot better than you're feeling. But he says he's sick—most probably with a problem you can't verify. A group from Scotland studied how doctors managed sickness certification and found that most feel uncomfortable (p 88). “I've no discrimination at all,” says one doctor. “If a patient comes in and says ‘I need to be off for two weeks… with a cold,’ I'll give him a Med 3 [a sickness certificate], no questions asked.” How can you tell a patient that he doesn't have a headache and should get back to work? It's not only philosophically untenable; it may also destroy the doctor patient relationship. “Once a patient didn't come back to me for 10 years because of me refusing her a sick line,” reports another doctor. “How,” asks a third doctor, “can we act as policeman, friend, social worker, and all the rest of it? We can't.”

    When asked to sign a certificate you are being asked to be an agent of the state—in particular, the Department for Work and Pensions. But it could be worse. You might be asked to examine an elderly and dishevelled man who has just been pulled from a hole in the ground. As you examine him for lice you see you're being filmed. What do you do? Push the camera away? You probably don't if you are an American army doctor examining Saddam Hussein, but both medical ethics and the Geneva Convention suggest you should (p 115). Samer Jabbour, a professor from Beirut, joins others in arguing that you are an agent of the state. But, worse still, you may be perceived as racist: “The video [shown across the world of Hussein being medically examined] was,” argues Jabbour, “a classic Orientalist display, portraying the oriental, barbarian appearing man, with long, uncombed, and dirty hair and beard, being cared for in a civilised manner by a white, clean doctor.”

    Medical systems—and doctors—are measured not by how they manage the grateful patient who bringswhisky but by how they care for terrorists, monsters, and the marginal. By demeaning Hussein the Coalition demeaned itself, its cause, and medicine.


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