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Analysis Essay

How medicine has exploited rationality at the expense of humanity: an essay by Iona Heath

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5705 (Published 01 November 2016) Cite this as: BMJ 2016;355:i5705

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Re: How medicine has exploited rationality at the expense of humanity: an essay by Iona Heath

This is a very thoughtful article by Iona Heath illustrating the downside of straight jacketed medicine, typified by strict adherence to evidence based medicine and "objective" data. It is somewhat akin to farming! To take one example - the battery chicken - she adheres to the protocol, is controlled and takes the recommended diet and light exposure. Sure enough she lays the most eggs, but her chilled out free ranger who eats whatever and whenever and gets tucked in for a good night's sleep, lays fewer but much nicer and richer eggs. Any school child knows a battery egg (pale and insipid yolk) from the deep rich yellow hue of the free range egg.

All patients, and even humans are free range. As Iona says they have their lives and hopes and sufferings and inner world. They are not the sum total of their bio-psycho-social data. They are people who want to be acknowledged and recognised as such, and also, by the way, they also have medical or social or psychiatric issues they would like some help with. The free range chicken can pick (sorry) and choose, and people are the same. Sometimes they are OK and all they want is a cholesterol test or a new hip and they are fine. Other times it is not so obvious. The hip or cholesterol test is only a facade for a deeper issue that requires a good conversation with a listening doctor.

The miracle question in child psychiatry is very revealing. You establish rapport with the child and ask them "how do you feel?" and they actually tell you. With adults the same can be a great question "how are you?" and they may actually tell you. This is not to side track the evidence base of the science of medicine but to tee it up to see how best to apply it. Communication empathy and rapport can take time, are soft skills, but really mean a lot to patients. Sometimes car mechanics and check out girls in supermarkets show great emotional skill, and it makes you want to return there for your next purchase. Doctors see people at very vulnerable stages in their lives (not ignoring the fact that sometimes "patients" have issues, are difficult and possibly obstructive), and therefore something more than what happens at a supermarket check out needs to happen. The science of medicine has left the art of medicine in its wake. Is medicine geared to do all the science and yet have the touchy feely side as well? Is it too big an ask? Maybe every doctor should have a chaperone to add the human side and the human understanding to the consultation - the doctor gets the history and does the treating, and the chaperone picks up the emotional fall out and does the psychological and human healing! The role of the doctor, and skills a doctor requires, need to be redefined in view of litigation, evidence based medicine, stress levels, expectations and patient demands.

I think if doctors are going to be involved with suffering people, and people in need, they should have a course on the skills necessary to engage with these people in a mutually satisfactory way. The biggest cause of litigation is a lack of communication (Medical Protection Society) and yet there are very few if any such courses in undergraduate curricula.

Competing interests: No competing interests

01 November 2016
eugene g breen
psychiatrist
62/63 Eccles St Dublin 7