The confidence to doubt
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39524.482535.47 (Published 20 March 2008) Cite this as: BMJ 2008;336:0
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I couldn't agree more with Drs Hedge, Nehrlich and Nambiar - the emphasis of ‘modern medicine’ and the ‘health care system’ on disease is perverting the essence of medicine. To quote Archie Cochrane – ‘In particular I believe that cure is rare while the need for care is widespread, and that the pursuit of cure at all costs may restrict the supply of care.’
My own research has led me to the conclusion that “the core value of medical care is the improvement of personal health, the value inherent and constant since the beginnings of medicine, and that the achievement of personal health depends on an ongoing, personal healing relationship with the doctor” (1). As every clinical trial has shown care is salutogenic in its own right (ironically this has been termed Hawthorne effect) despite the fact that psychoneuroimmunology research has provided a ‘scientific explanation’ for this ‘undesirable side effect’ of doing a trial.
The prevailing machine metaphor of the functioning of the body and the understanding of disease being a broken part that can be fixed or replaced may fit the ‘disease management approach’ of the ‘health care bureaucracy’ and the rare occasion where there actually is a cure.
However, virtually all of our health and illness experiences are embedded in a huge network of relationships – be it internally with the multiple simultaneous biochemical/hormonal/electrophysiological actions maintaining our internal homeostasis, or externally with our homes and families, communities, work and the larger physical environment. All of these are constantly feeding back on each other, we are in constant flux, adapting and emerging to some as yet unknown – speak: risky – state. Holistically looking at health means accepting our interconnectedness and interdependence with the world we live in, a complex world, a world that is not predictable and frequently not kind. To that end a risk factor is only that, all of us accept lots of risk factors (e.g. driving a car), but only a few will have ill effects from these – how risk plays out in someone’s life will always remain to be seen.
There is probably only one way to approach this ‘risk called life’, take reasonable ‘common sense’ precautions and take care of yourself, at times with the help of your personal caring doctor.
(1) Sturmberg J. The Foundations of Primary Care – daring to be different. Radcliffe Publishing: Oxford;2007
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I read with interest Dr Hegdes comments.I perfectly agree with dr Hegde.Whats missing in medical practice now a days is the personal touch.I grew up in a remote willage in Kerala where we only had traditional medical practioners.I remember once when I was about 7 years old I had Chicken Pox.Only medicine that I was given was an elixir made of Neem leaf.I recovered of the infection but I had paralysis of both lower limbs after about 7 days,which I presume was due to Gullien Barrie Syndrome.There were no Doctors those days only traditional medicines were avaialble.I did not take any medicines , but I recovered fully with no residual effects.But I faintly remember now is only the comforting words of a traditional practioner who just reassured me.I am sure if I were to get the same now , I would have been in ICU , on ventilator and may not be alive to write this today.
Modern Medicine is driven by commercial interests,and modern medicine lacks a personal touch.
Patents many a time survive despite Doctors.And I perosnally feel sometimes as in my case, no treatment sometimes is better than treatment.
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Having followed the writings of Professor Hegde I must say that few if any contributors to the BMJ Rapid Response section offer more in the way of useful information, of food for thought for us in the trenches.
His statement "Doctors could get better compliance from their patients if only they spent quality time with their patients to listen to their woes and understand them..."
is a typical example of common sense applied and not lost in the jungle of hands on patient care and the obligations of academia.
Yes, there is no place for malice when it comes to dealing with fellow mortals who are sick; Hegde reminds me of Skrabanek without the tobacco addiction.
I can observe a trend, a small movement if you wish, toward the re-establishment of the personal interaction between physician and patient. How great that will be!
We all remember that favourite teacher of ours at the very beginning of our school years. I for one did most of my learning for her.She did live by the principle of "Non Scholae Sed Vitae Discimus" but her smile and personal attention was what did the trick. It was an aphrodisiac and it was curative.
Having reached a rather respectable age I still remember with great fondness and affection my personal country doctor, a man by the name of Pudenz. His name sounded like a new medicament but he didn't prescribe many.He was a friend to all of his patients and he walked with them, only to stop at the Pearly Gate at the last minute.
What cured then and what will always be the deciding factor is not the silly pills and potions with their huge mark-ups but the compassion of man for his fellow man.
If you take the time to read Professor Hegde's comments you will know exactly what I mean and you may come to admire him as much as I do.
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Dear Fiona Godlee,
I would like to be in the pit without any mud in hand and without malice to any one.
In the first place, there should be no divide between academia and clinical practice; they should complement each other. There is no academia without bedside inputs and vice versa. Sir William Osler, I think, that said that learning medicine without books is like swimming an uncharted sea while learning medicine without books is not going to sea at all or, something to that effect. Learn one must all his/her life, though. Some of us have extra curricular (academic) interest in keeping this debate alive as it serves the pharma industry well. “Risk factors” business makes literally every one above the age of thirty a life long client for some company or the other although the life of the recipient might thereby get shorter. While the pills thrill, they could also kill.
The “thought leaders” on either side of the metabolic syndrome X argument have lost sight of the most important aspect of their quarrel that the syndrome, either in the academia or in practice, has very little, if any, predictive value, since human body’s time evolution is not linear, anyway. Future prediction does not depend on one or two of the initial body parameters, be it the waist size or the buttock size! It would be easier to practise medicine if the physician attempts to get patients to change their mode of living if obese. It should be a holistic approach and not reductionistic as of now.
Renaissance humanism, although considered anti-church at that time (Faustus I), teaches us to be human and humane in our approach to humankind. Medical humanism is good patient care. Patient care simply means caring for the patient. All the other papers referred to in your editorial will do well with these comments. Doctors could get better compliance from their patients if only they spent quality time with their patients to listen to their woes and understand them. Better compliance with life style modification advice of the physician would bring out better long term results in type II diabetes in contrast to all the drugs.
Yours ever, bmhegde
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We need to go back
I agree with all the four responders.We need to go back again lead the simple life our ancestors lead and we will be a happy society once again.
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