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DANGER! DOCTORS AT WORK
1226
Points of View DANGER! DOCTORS AT WORK
*
JOHN FORBES M.D.
Lond., F.R.C.P.
CONSULTANT
PHYSICIAN, WREXHAM HOSPITALS Even if doctors apply all their knowledge, and act in good faith, they often do harm when they think to do good."—HENRI ESTIENNE "
(1528-1598), Apology for Herodotus. MOST of us, if asked whether we thought we did more good than harm to our patients by our doctoring, would be slightly astonished and mildly affronted. We are
accustomed
to think of ourselves as benevolent members of society; but, although we are on balance almost certainly justified in our belief, the truth of the assumption is not as self-evident as we might think. A century or two ago, when bleeding and purgation were common practice, and surgery was crude butchery, it is not unlikely that, as many contemporary critics said, doctors killed more people than they cured. Even today we can, unwittingly and with the best intentions, do quite a lot of harm, either individually to our own patients or, as a profession, to the
community. There are four chief reasons why honest, hard-working, and conscientious doctors sometimes do harm when they think to do good: they are ignorance, misdirected enthusiasm, over-confidence, and timidity. Individual ignorance does not arise, because the conscientious doctor is not ignorant, at least so far as medicine is concerned. But we must consider the question of ignorance in the wider sense among the medical profession as a whole. It has to be admitted that most doctors compare poorly with other professional men when it comes to a knowledge of such things as literature, philosophy, logic, economics, and even science. (We deceive ourselves if we think that we are trained in scientific method. A few may be, but the majority of clinicians certainly are not. Ask any real scientist.) Medicine is such a vast and absorbing study, and the course of training for it so long and exacting, that most of us have little time or inclination to dabble in other branches of learning-though there have been, of course, notable exceptions. Doctors are often too busy and too tired to take an active part in non-medical intellectual societies. Even at social gatherings we tend to talk too much about medicine (this is not entirely our fault, for laymen love to discuss medical topics). And it may be that we flock together too much and have too many professional discussion groups, which meet too often. The unfortunate result is that our comparative ignorance of non-medical subjects may sometimes lead us, as a profession, into error. We are liable to be led astray by ideas that are based on unsound premises or on fallacious reasoning. Many of the false gods that we have worshipped in the past, such as Focal Sepsis, Intestinal Autointoxication, and Vitamin Therapy, might never have achieved the popularity that they did if more doctors had been better trained in logic and in the appraisal of scientific data. Those who would reduce the time spent by medical students on general education and the basic sciences should ponder this. Enthusiasm is a virtue and a particular asset of youth. Happy is the man who can preserve it into middle age * Presidential address to the North Wales Branch of the Britisl Medical Association, June 7, 1958.
and beyond, tempering it with prudence and experience. Most of us were full of enthusiasm when we qualified, and tended to over-investigate and over-treat our patients, until we came to appreciate the healing powers of the vis medicatrix natural and the remarkable tendency of patients to get better whatever we did. Youthful enthusiasm is certainly not to be discouraged, and even when excessive is less harmful than sloth. It becomes dangerous, however, when it is not checked by experience and common sense, and degenerates into crankiness, Cranks are a menace: the scalpel-happy surgeon with a pet operation, the physician with a taste for amateur " research " which involves puncturing his patients’ vital organs, the psychiatrist with a kink in his own psyche, the specialist who sees all disease in terms of his own narrow specialty-these do harm to their patients, if not by actual maltreatment then by wasting their time with useless therapy. Established cranks are deaf to logic and blind to statistics. We must all watch ourselves for the early symptoms and signs of misdirected enthusiasm, and take steps to treat them with large doses of sceptical common sense. A few bees in the bonnet may be permitted to grey hairs; but a swarm is a sign of
senility. Communal bonnet-swarming is liable to occur when large numbers of doctors are sold an idea which is attractive in theory. In therapeutics a new myth is born every minute. It would be salutary if each of us were to be confronted with all his prescriptions for the past ten or twenty years and compelled to read therein the record of his ephemeral therapeutic enthusiasms. Luckily, most of them probably did no great harm; which is more than can be said for some of the misguided enthusiasms of our surgical brethren. As Robert Burns nearly said, "Though you cut his vagus nerves, a man’s a man for a’ that"; but can the same be said if you cut his lumbar sympathetic
chain ? Misdirected enthusiasm is common in the sphere of public health and preventive medicine. The peculiar danger here is the keen medical administrator with a passion for planning, coordination, team-work, liaison, and lots and lots of statistical data. He is liable to produce
elaborate schemes which look very nice on paper but which, after putting everybody to a great deal of trouble, somehow do not seem to work out very well in practice, To be fair, it is not always his fault; for he is often under pressure from his political masters, who like nothing better than the feeling of power that they get from organising other people’s lives for them. For the past ten years we have in this country had a prolonged epidemic of administrative enthusiasm, which is probably an inevitable concomitant of a National Health Service and a Welfare State. There is, of course, no surer path to preferment in administrative circles than to be fertile in planning. Moreover, the rapid increase in the number of administrative staff in our hospital services since 1948 has meant that more officials have more time to plan schemes. Parkinson has summed up the position in his Law: " Work expands to fill the time available for its completion ", and in his further axiom: "Officials make work for one another." Many doctors believe that the Mass Radiography Service is a good example of presentday misdirected administrative enthusiasm. Originally a good idea, when it was used to survey selected groups of the population, it has expanded into an expensive and
undiscriminating travelling circus,
with advertising
to
1227
match. It is possible that we may be faced before long with a similar scheme for routine medical examinations, " health-checks ". These are already popular in or Russia and in the U.S.A., though they are not in the latter country carried out at public expense. Such a programme seems a not unlikely target for the next outburst of misdirected administrative enthusiasm. It may be asked how such misplaced zeal can actually harm the community, apart from depleting its pocket. The answer is, by its effect on the public mind. It is unfortunately true that much well-meant health propaganda today does encourage thoughts of disease and an obsession with bodily well-being. There is a danger that we may turn the British into a nation of hypochondriacs; some would say that we are already doing so. Criticism of so-called positive-health schemes and propaganda is not popular, and lays one open to accusations of obscurantism and cerebral arteriosclerosis. No-one would be so foolish as to deny the great benefits that we have received in the past from advances in public health and social medicine; but these have been largely achieved by improvements in the standard of living, which frightens no-one. Today the propaganda is more personal, more alarming for the individual. Are we (and in this we cannot absolve our own profession from blame) not in danger of making a fetish of bodily health ? Might we not spend the money more profitably on propaganda for spiritual health ? Over-confidence is a failing chiefly found among senior consultants. Its chief manifestations are a scarcely veiled contempt for general-practitioner colleagues, a strong tendency to dogmatic assertions based on my experience " (often imperfectly recalled), and a more or less complete deafness to the opinions of others. There is an inclination to leap to premature conclusions, and an equal reluctance to admit that they could be wrong. Diagnostic errors are therefore common, but are usually covered up cleverly, patients being bamboozled by a bluff, selfconfident manner, and family doctors misled by judicious prevarications and half-truths. The great man’s registrar sees through it all, of course, but does not dare to open his lips till he too is a senior consultant. Want of humility may show itself in other ways. There is, for example, the doctor with an overdeveloped sense of mission. Such a one sees himself, unconsciously perhaps, as a Healer. No-one would deny that a proper consciousness of vocation is desirable in a medical man, but these Dr. Kildares carry it to extremes. They are, of "
basically hysterical personalities with a taste for dramatics. Their patients are fussed over till they and their relatives develop anxiety states, are literally " rushed " to hospital whenever opportunity offers, and may even undergo unnecessary operations because their doctor needs to feel that he is doing them some positive course,
good. Timidity shows itself
in the field of or in under-treatment. An example of over-care is the patient with a mild coronary thrombosis who is confined to bed for three months and afterwards forbidden to smoke, drink, or engage in his favourite recreations-all quite unnecessarily. Children are sometimes kept in bed for weeks with vague " rheumatism " when there is really nothing the matter with them, simply because their doctor lacks the courage of his convictions. A timid doctor can very easily manufacture neurotics and chronic invalids, and the sad thing is that his patients are often pathe-
therapeutics, and
most
frequently
may result either in
over-care
tically grateful for his wonderful carefulness. On the other hand, timid under-treatment is not uncommon in these days of powerful drugs which are effective in proper dosage yet may have unpleasant side-effects or only a small safety margin. Ganglion-blocking agents and anticoagulants are good examples, for they must either be given in effective dosage or they might as well not be given at all. The temptation is to play safe by underprescribing. But half-measures have no place in therapeutics, and it may be necessary for the patient to live dangerously for a time if he is to live at all. Prognostic timidity results in a tendency to exaggerate the severity of an illness when discussing it with the relatives. The
temptation is strong, for the doctor can hardly lose. If the patient dies-well, he said it was serious. If, as is more likely, he recovers, the near-miracle was due to the skill and devotion of his medical attendant. A remarkable reputation can be built on prognostic pessimism. The habit does no great harm to the patient, but it causes needless anxiety to the relatives, and is really rather
contemptible. Finally, there is the$64 question: Does medicine as we practise it really benefit mankind in the long run ? It is possible to argue that doctors, by saving the lives of mental defectives, hxmophiliacs, diabetics, and the like, are perpetuating undesirable genetic strains that would otherwise die out; and that by keeping old people alive they are throwing an ever-increasing economic burden on to the younger members of the community. Philosophers may argue these points as they will; we, as doctors, are not required to answer them. A doctor’s task is to heal the sick and to alleviate suffering, without thought of his patient’s age, colour, nationality, religion, or social worth. If he departs from this principle he is lost. The only really serious danger of any system of State medicine is that economic or political considerations might come to be regarded as important enough to interfere seriously with it. Such a contingency is remote in this country, but we have seen it happen under totalitarian regimes elsewhere.
Public Health The
Registrar General’s Commentary
IN his commentary on the vital statistics for 1956 the Registrar Generalremarks that in that year the infantmortality rate of 23-7 per 1000 related live births was one of the lowest in the world; in Europe, only Sweden and the Netherlands had lower rates. Between 1951 and 1956 the infant-mortality rate declined by 20%. Over 70% of the deaths occurred in the first four weeks of life. Boy babies appeared more liable to die from almost any cause, accidental or other, than girl babies. Births.-The birth-rate of 15-6 per 1000 population was 0-6 higher than in 1955. This increase continued the rise which began in the late spring of 1955; until then the rate had been fairly constant since 1951. (This upward trend continued in 1957, and the birth-rate for that year proved to be the highest for eight years.) The long-term prospects are that current generations are likely to replace themselves with a little to spare, completed families being of rather more than two children on average. Divorce and remarriage.-The number of divorce decrees granted continued to decline, from 26,816 in 1955 to 26,265 in 1. The Registrar General’s Statistical Review for England and Wales, 1956 Part III, Commentary. H.M. Stationery Office. Pp. 294. 16s, 6d.
Points of View DANGER! DOCTORS AT WORK
*
JOHN FORBES M.D.
Lond., F.R.C.P.
CONSULTANT
PHYSICIAN, WREXHAM HOSPITALS Even if doctors apply all their knowledge, and act in good faith, they often do harm when they think to do good."—HENRI ESTIENNE "
(1528-1598), Apology for Herodotus. MOST of us, if asked whether we thought we did more good than harm to our patients by our doctoring, would be slightly astonished and mildly affronted. We are
accustomed
to think of ourselves as benevolent members of society; but, although we are on balance almost certainly justified in our belief, the truth of the assumption is not as self-evident as we might think. A century or two ago, when bleeding and purgation were common practice, and surgery was crude butchery, it is not unlikely that, as many contemporary critics said, doctors killed more people than they cured. Even today we can, unwittingly and with the best intentions, do quite a lot of harm, either individually to our own patients or, as a profession, to the
community. There are four chief reasons why honest, hard-working, and conscientious doctors sometimes do harm when they think to do good: they are ignorance, misdirected enthusiasm, over-confidence, and timidity. Individual ignorance does not arise, because the conscientious doctor is not ignorant, at least so far as medicine is concerned. But we must consider the question of ignorance in the wider sense among the medical profession as a whole. It has to be admitted that most doctors compare poorly with other professional men when it comes to a knowledge of such things as literature, philosophy, logic, economics, and even science. (We deceive ourselves if we think that we are trained in scientific method. A few may be, but the majority of clinicians certainly are not. Ask any real scientist.) Medicine is such a vast and absorbing study, and the course of training for it so long and exacting, that most of us have little time or inclination to dabble in other branches of learning-though there have been, of course, notable exceptions. Doctors are often too busy and too tired to take an active part in non-medical intellectual societies. Even at social gatherings we tend to talk too much about medicine (this is not entirely our fault, for laymen love to discuss medical topics). And it may be that we flock together too much and have too many professional discussion groups, which meet too often. The unfortunate result is that our comparative ignorance of non-medical subjects may sometimes lead us, as a profession, into error. We are liable to be led astray by ideas that are based on unsound premises or on fallacious reasoning. Many of the false gods that we have worshipped in the past, such as Focal Sepsis, Intestinal Autointoxication, and Vitamin Therapy, might never have achieved the popularity that they did if more doctors had been better trained in logic and in the appraisal of scientific data. Those who would reduce the time spent by medical students on general education and the basic sciences should ponder this. Enthusiasm is a virtue and a particular asset of youth. Happy is the man who can preserve it into middle age * Presidential address to the North Wales Branch of the Britisl Medical Association, June 7, 1958.
and beyond, tempering it with prudence and experience. Most of us were full of enthusiasm when we qualified, and tended to over-investigate and over-treat our patients, until we came to appreciate the healing powers of the vis medicatrix natural and the remarkable tendency of patients to get better whatever we did. Youthful enthusiasm is certainly not to be discouraged, and even when excessive is less harmful than sloth. It becomes dangerous, however, when it is not checked by experience and common sense, and degenerates into crankiness, Cranks are a menace: the scalpel-happy surgeon with a pet operation, the physician with a taste for amateur " research " which involves puncturing his patients’ vital organs, the psychiatrist with a kink in his own psyche, the specialist who sees all disease in terms of his own narrow specialty-these do harm to their patients, if not by actual maltreatment then by wasting their time with useless therapy. Established cranks are deaf to logic and blind to statistics. We must all watch ourselves for the early symptoms and signs of misdirected enthusiasm, and take steps to treat them with large doses of sceptical common sense. A few bees in the bonnet may be permitted to grey hairs; but a swarm is a sign of
senility. Communal bonnet-swarming is liable to occur when large numbers of doctors are sold an idea which is attractive in theory. In therapeutics a new myth is born every minute. It would be salutary if each of us were to be confronted with all his prescriptions for the past ten or twenty years and compelled to read therein the record of his ephemeral therapeutic enthusiasms. Luckily, most of them probably did no great harm; which is more than can be said for some of the misguided enthusiasms of our surgical brethren. As Robert Burns nearly said, "Though you cut his vagus nerves, a man’s a man for a’ that"; but can the same be said if you cut his lumbar sympathetic
chain ? Misdirected enthusiasm is common in the sphere of public health and preventive medicine. The peculiar danger here is the keen medical administrator with a passion for planning, coordination, team-work, liaison, and lots and lots of statistical data. He is liable to produce
elaborate schemes which look very nice on paper but which, after putting everybody to a great deal of trouble, somehow do not seem to work out very well in practice, To be fair, it is not always his fault; for he is often under pressure from his political masters, who like nothing better than the feeling of power that they get from organising other people’s lives for them. For the past ten years we have in this country had a prolonged epidemic of administrative enthusiasm, which is probably an inevitable concomitant of a National Health Service and a Welfare State. There is, of course, no surer path to preferment in administrative circles than to be fertile in planning. Moreover, the rapid increase in the number of administrative staff in our hospital services since 1948 has meant that more officials have more time to plan schemes. Parkinson has summed up the position in his Law: " Work expands to fill the time available for its completion ", and in his further axiom: "Officials make work for one another." Many doctors believe that the Mass Radiography Service is a good example of presentday misdirected administrative enthusiasm. Originally a good idea, when it was used to survey selected groups of the population, it has expanded into an expensive and
undiscriminating travelling circus,
with advertising
to
1227
match. It is possible that we may be faced before long with a similar scheme for routine medical examinations, " health-checks ". These are already popular in or Russia and in the U.S.A., though they are not in the latter country carried out at public expense. Such a programme seems a not unlikely target for the next outburst of misdirected administrative enthusiasm. It may be asked how such misplaced zeal can actually harm the community, apart from depleting its pocket. The answer is, by its effect on the public mind. It is unfortunately true that much well-meant health propaganda today does encourage thoughts of disease and an obsession with bodily well-being. There is a danger that we may turn the British into a nation of hypochondriacs; some would say that we are already doing so. Criticism of so-called positive-health schemes and propaganda is not popular, and lays one open to accusations of obscurantism and cerebral arteriosclerosis. No-one would be so foolish as to deny the great benefits that we have received in the past from advances in public health and social medicine; but these have been largely achieved by improvements in the standard of living, which frightens no-one. Today the propaganda is more personal, more alarming for the individual. Are we (and in this we cannot absolve our own profession from blame) not in danger of making a fetish of bodily health ? Might we not spend the money more profitably on propaganda for spiritual health ? Over-confidence is a failing chiefly found among senior consultants. Its chief manifestations are a scarcely veiled contempt for general-practitioner colleagues, a strong tendency to dogmatic assertions based on my experience " (often imperfectly recalled), and a more or less complete deafness to the opinions of others. There is an inclination to leap to premature conclusions, and an equal reluctance to admit that they could be wrong. Diagnostic errors are therefore common, but are usually covered up cleverly, patients being bamboozled by a bluff, selfconfident manner, and family doctors misled by judicious prevarications and half-truths. The great man’s registrar sees through it all, of course, but does not dare to open his lips till he too is a senior consultant. Want of humility may show itself in other ways. There is, for example, the doctor with an overdeveloped sense of mission. Such a one sees himself, unconsciously perhaps, as a Healer. No-one would deny that a proper consciousness of vocation is desirable in a medical man, but these Dr. Kildares carry it to extremes. They are, of "
basically hysterical personalities with a taste for dramatics. Their patients are fussed over till they and their relatives develop anxiety states, are literally " rushed " to hospital whenever opportunity offers, and may even undergo unnecessary operations because their doctor needs to feel that he is doing them some positive course,
good. Timidity shows itself
in the field of or in under-treatment. An example of over-care is the patient with a mild coronary thrombosis who is confined to bed for three months and afterwards forbidden to smoke, drink, or engage in his favourite recreations-all quite unnecessarily. Children are sometimes kept in bed for weeks with vague " rheumatism " when there is really nothing the matter with them, simply because their doctor lacks the courage of his convictions. A timid doctor can very easily manufacture neurotics and chronic invalids, and the sad thing is that his patients are often pathe-
therapeutics, and
most
frequently
may result either in
over-care
tically grateful for his wonderful carefulness. On the other hand, timid under-treatment is not uncommon in these days of powerful drugs which are effective in proper dosage yet may have unpleasant side-effects or only a small safety margin. Ganglion-blocking agents and anticoagulants are good examples, for they must either be given in effective dosage or they might as well not be given at all. The temptation is to play safe by underprescribing. But half-measures have no place in therapeutics, and it may be necessary for the patient to live dangerously for a time if he is to live at all. Prognostic timidity results in a tendency to exaggerate the severity of an illness when discussing it with the relatives. The
temptation is strong, for the doctor can hardly lose. If the patient dies-well, he said it was serious. If, as is more likely, he recovers, the near-miracle was due to the skill and devotion of his medical attendant. A remarkable reputation can be built on prognostic pessimism. The habit does no great harm to the patient, but it causes needless anxiety to the relatives, and is really rather
contemptible. Finally, there is the$64 question: Does medicine as we practise it really benefit mankind in the long run ? It is possible to argue that doctors, by saving the lives of mental defectives, hxmophiliacs, diabetics, and the like, are perpetuating undesirable genetic strains that would otherwise die out; and that by keeping old people alive they are throwing an ever-increasing economic burden on to the younger members of the community. Philosophers may argue these points as they will; we, as doctors, are not required to answer them. A doctor’s task is to heal the sick and to alleviate suffering, without thought of his patient’s age, colour, nationality, religion, or social worth. If he departs from this principle he is lost. The only really serious danger of any system of State medicine is that economic or political considerations might come to be regarded as important enough to interfere seriously with it. Such a contingency is remote in this country, but we have seen it happen under totalitarian regimes elsewhere.
Public Health The
Registrar General’s Commentary
IN his commentary on the vital statistics for 1956 the Registrar Generalremarks that in that year the infantmortality rate of 23-7 per 1000 related live births was one of the lowest in the world; in Europe, only Sweden and the Netherlands had lower rates. Between 1951 and 1956 the infant-mortality rate declined by 20%. Over 70% of the deaths occurred in the first four weeks of life. Boy babies appeared more liable to die from almost any cause, accidental or other, than girl babies. Births.-The birth-rate of 15-6 per 1000 population was 0-6 higher than in 1955. This increase continued the rise which began in the late spring of 1955; until then the rate had been fairly constant since 1951. (This upward trend continued in 1957, and the birth-rate for that year proved to be the highest for eight years.) The long-term prospects are that current generations are likely to replace themselves with a little to spare, completed families being of rather more than two children on average. Divorce and remarriage.-The number of divorce decrees granted continued to decline, from 26,816 in 1955 to 26,265 in 1. The Registrar General’s Statistical Review for England and Wales, 1956 Part III, Commentary. H.M. Stationery Office. Pp. 294. 16s, 6d.