- Email: [email protected]
A FRUITLESS SEARCH FOR THE NEW APPROACH
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profession may be obtuse, but also because of the very long time-scale needed to induce attitudinal change.
Occasional Book
The reformers do have their effects, however, though they may perceive them. Look through the several Recommendations as to Basic Medical Education of the General Medical Council, witness the resurgence of general practice with its well-developed philosophy of caring for the whole patient, the rise of geriatrics, and the burgeoning of psychiatry. The progress may not be far enough nor fast enough, but it is there and is evidence of changed attitudes within and outside medicine. It does not matter who is responsible for the changes, but it is notable that Inglis draws heavily on the evidence of critical doctors. He has many allies, one might almost say fifth-columnists, within medicine. As busily as some build the citadel there are some attacking the base, since they are not so sure that the builders have the edifice right. not
A FRUITLESS SEARCH FOR THE NEW APPROACH
THE dustcover of Brian Inglis’s new book’ proclaims that this is "An indictment of traditional methods of medical treatment and a plea for a completely new approach". It is said not to be an exercise in doctor-bashing. Montaigne’s dictum on physicians is quoted with approval: "I have known many a good man among them, and most worthy of my affection. I do not attack them, but their art". Evidently Montaigne had a certain arrogance in believing that others cared where he bestowed his affection and that his criticisms should be heeded. It may even be thought that the art could be inseparable from its practitioners, but that must be allowed to pass. Nevertheless, there is a sense in which all ofus are entrapped in the modes of thought and action in which we are reared: It is hard to step outside our own time and place and slough off the carapace which may be constricting us and our development. We can become too comfortable within it and be unappreciative when we are prised out of it. This is why Inglis’s book is to be welcomed and not dismissed as just another of those pronouncements which doctors
have
lately come to expect.
The tradition being followed is that of Dubos’s Mirage of Health, Illich’s Medical Nemesis, Carlson’s The End of Medicine, McKeown’s The Role of Medicine, and Kennedy’s recent Reith lectures. They are a formidable bunch of critics extending over about 45 years, and there have been many before them. All is not well nor right with medicine, they say. They diagnose what is wrong as it seems to them and produce a policy for putting matters right. There is a certain irony in them (that is, Illich, Carlson, Kennedy, and Inglis) behaving so like doctors. And an even greater irony when they find that doctors disagree with them, just as doctors disagree among themselves. In difficult cases (and the state of medicine is difficult) doctors do disagree. Some may not even be sure if the patient is sick at all, and, if he is, just how sick. Depending on this judgment are based prescriptions for palliation or root-and-branch surgery.
What may be surprising to the critics is that a large number of doctors will agree with many of their strictures. After Illich and Kennedy, when the first brouhaha had died down, a great many doctors felt that some valuable things had been said about medicine which were worthy of heed. But neither the whole diagnosis nor the whole treatment could be fully accepted. The same will happen with this book. There is no reason why it should be otherwise. The patient has his rights as well as the doctor, as Inglis rightly emphasises. The heaviest thrust of criticism is made against the medical establishment. It is difficult to know what this is. It is something like the public opinion so beloved of politicians, nebulous in concept and forced into any mould made to fit the orator’s or writer’s preconceptions. What may be meant by the medical establishment is that body of doctors who shape and form the attitudes and beliefs of the medical profession in the mass. Essentially these are presumably the teachers, writers, and shapers of medical policy in colleges and faculties and myriad other places-in short, the educators (and among these are the journalists, both lay and medical). But education in its very widest sense is about modifying and changing behaviour, both in action and thought. Its major long-term effects are in changing attitudes. These are what change the uses to which knowledge and skills are put. This is what Inglis and the others are trying to do-bring about a change in the thinking and action of the whole medical profession. It is not surprising perhaps that they fail, not only because the
1. The Diseases of Civilisation.
Pp. 371. £10.95.
By Brian Inglis.
London: Hodder and
Stoughton. 1981.
In detail Inglis is damning and often right. Doctors will be familiar with much that he criticises-blood-pressure control, clofibrate, coronary-artery bypass, coronary-care units, lung-cancer prevention and treatment, breast cancer, screening for cervical cancer, mental illness and the place of ECT, leucotomy and drugs, iatrogenic disorders, neuroepidemics, such as that of the Royal Free disease, autoimmune diseases, relationships with the pharmaceutical industry, and the ethics of research. All these problems are still with us and the arguments rage about them. What I think Inglis is saying is that few if any of these are or will be soluble within the present medical model. (This horrible jargon term probably means the preconceptions which doctors are presumed to have when they deal with the problems of illness.) Other models seem to be accepted without question unfortunately and are not subject to the same rigorous scrutiny as medicine. This weakens the force of the attack, and for me that is regrettable, for there seems to me to be disorder in medicine which would be better put right.
.
Inglis highlights the failures very well, but superficial considerations of psychosomatic
then hives off into illness and social factors in the cause of disease. There are some notions too that bacteria may not be the cause of disease but markers of illness which has arisen independently of infection. Maybe Koch’s postulates are not always fulfilled in every infection, but his evidence for not recognising legionnaire’s disease as due to an infecting external agent is thin. He places much reliance in his interpretations on constitutional factors, though this is not a term he uses. What seems to have escaped him is that every doctor is aware of these and is puzzled by the fact that some people succumb to diseases while others do not, and yet superficially those people seem to be similar. Clues as to constitution do arise from genetics and from investigation of personality traits, and these are factors in many diseases. Yet they are hard to identify, as Inglis realises, and his certainty that they are always important cannot be unequivocally shared by others. They do enter into every disorder in some degree, but it is how far they enter that is still a matter for debate, in the absence of firmer evidence than the author is able to muster. He has often mistaken small signposts of direction for the high road itself. Anything on the edge of orthodox medicine, especially when it is iconoclastic, is accepted as the way to the truth. So it may be, but whether you believe it depends on presuppositions which are not wholly shared. The feeble part of the book is the "completely new approach". Everything said here has been said before and sometimes with more cogency by doctors themselves. The final sentence of the book declares "... we can try to achieve a better understanding of ourselves through a liberation of instincts long dormant, and where necessary a change in our life-style". That seems sensible enough perhaps, but how on earth do we bring it about? It is in not answering that Inglis disappoints. There is not the revelation I had hoped for. Postgraduate Department, Southampton General Hospital, Southampton SO9 4XY
PHILIP RHODES
profession may be obtuse, but also because of the very long time-scale needed to induce attitudinal change.
Occasional Book
The reformers do have their effects, however, though they may perceive them. Look through the several Recommendations as to Basic Medical Education of the General Medical Council, witness the resurgence of general practice with its well-developed philosophy of caring for the whole patient, the rise of geriatrics, and the burgeoning of psychiatry. The progress may not be far enough nor fast enough, but it is there and is evidence of changed attitudes within and outside medicine. It does not matter who is responsible for the changes, but it is notable that Inglis draws heavily on the evidence of critical doctors. He has many allies, one might almost say fifth-columnists, within medicine. As busily as some build the citadel there are some attacking the base, since they are not so sure that the builders have the edifice right. not
A FRUITLESS SEARCH FOR THE NEW APPROACH
THE dustcover of Brian Inglis’s new book’ proclaims that this is "An indictment of traditional methods of medical treatment and a plea for a completely new approach". It is said not to be an exercise in doctor-bashing. Montaigne’s dictum on physicians is quoted with approval: "I have known many a good man among them, and most worthy of my affection. I do not attack them, but their art". Evidently Montaigne had a certain arrogance in believing that others cared where he bestowed his affection and that his criticisms should be heeded. It may even be thought that the art could be inseparable from its practitioners, but that must be allowed to pass. Nevertheless, there is a sense in which all ofus are entrapped in the modes of thought and action in which we are reared: It is hard to step outside our own time and place and slough off the carapace which may be constricting us and our development. We can become too comfortable within it and be unappreciative when we are prised out of it. This is why Inglis’s book is to be welcomed and not dismissed as just another of those pronouncements which doctors
have
lately come to expect.
The tradition being followed is that of Dubos’s Mirage of Health, Illich’s Medical Nemesis, Carlson’s The End of Medicine, McKeown’s The Role of Medicine, and Kennedy’s recent Reith lectures. They are a formidable bunch of critics extending over about 45 years, and there have been many before them. All is not well nor right with medicine, they say. They diagnose what is wrong as it seems to them and produce a policy for putting matters right. There is a certain irony in them (that is, Illich, Carlson, Kennedy, and Inglis) behaving so like doctors. And an even greater irony when they find that doctors disagree with them, just as doctors disagree among themselves. In difficult cases (and the state of medicine is difficult) doctors do disagree. Some may not even be sure if the patient is sick at all, and, if he is, just how sick. Depending on this judgment are based prescriptions for palliation or root-and-branch surgery.
What may be surprising to the critics is that a large number of doctors will agree with many of their strictures. After Illich and Kennedy, when the first brouhaha had died down, a great many doctors felt that some valuable things had been said about medicine which were worthy of heed. But neither the whole diagnosis nor the whole treatment could be fully accepted. The same will happen with this book. There is no reason why it should be otherwise. The patient has his rights as well as the doctor, as Inglis rightly emphasises. The heaviest thrust of criticism is made against the medical establishment. It is difficult to know what this is. It is something like the public opinion so beloved of politicians, nebulous in concept and forced into any mould made to fit the orator’s or writer’s preconceptions. What may be meant by the medical establishment is that body of doctors who shape and form the attitudes and beliefs of the medical profession in the mass. Essentially these are presumably the teachers, writers, and shapers of medical policy in colleges and faculties and myriad other places-in short, the educators (and among these are the journalists, both lay and medical). But education in its very widest sense is about modifying and changing behaviour, both in action and thought. Its major long-term effects are in changing attitudes. These are what change the uses to which knowledge and skills are put. This is what Inglis and the others are trying to do-bring about a change in the thinking and action of the whole medical profession. It is not surprising perhaps that they fail, not only because the
1. The Diseases of Civilisation.
Pp. 371. £10.95.
By Brian Inglis.
London: Hodder and
Stoughton. 1981.
In detail Inglis is damning and often right. Doctors will be familiar with much that he criticises-blood-pressure control, clofibrate, coronary-artery bypass, coronary-care units, lung-cancer prevention and treatment, breast cancer, screening for cervical cancer, mental illness and the place of ECT, leucotomy and drugs, iatrogenic disorders, neuroepidemics, such as that of the Royal Free disease, autoimmune diseases, relationships with the pharmaceutical industry, and the ethics of research. All these problems are still with us and the arguments rage about them. What I think Inglis is saying is that few if any of these are or will be soluble within the present medical model. (This horrible jargon term probably means the preconceptions which doctors are presumed to have when they deal with the problems of illness.) Other models seem to be accepted without question unfortunately and are not subject to the same rigorous scrutiny as medicine. This weakens the force of the attack, and for me that is regrettable, for there seems to me to be disorder in medicine which would be better put right.
.
Inglis highlights the failures very well, but superficial considerations of psychosomatic
then hives off into illness and social factors in the cause of disease. There are some notions too that bacteria may not be the cause of disease but markers of illness which has arisen independently of infection. Maybe Koch’s postulates are not always fulfilled in every infection, but his evidence for not recognising legionnaire’s disease as due to an infecting external agent is thin. He places much reliance in his interpretations on constitutional factors, though this is not a term he uses. What seems to have escaped him is that every doctor is aware of these and is puzzled by the fact that some people succumb to diseases while others do not, and yet superficially those people seem to be similar. Clues as to constitution do arise from genetics and from investigation of personality traits, and these are factors in many diseases. Yet they are hard to identify, as Inglis realises, and his certainty that they are always important cannot be unequivocally shared by others. They do enter into every disorder in some degree, but it is how far they enter that is still a matter for debate, in the absence of firmer evidence than the author is able to muster. He has often mistaken small signposts of direction for the high road itself. Anything on the edge of orthodox medicine, especially when it is iconoclastic, is accepted as the way to the truth. So it may be, but whether you believe it depends on presuppositions which are not wholly shared. The feeble part of the book is the "completely new approach". Everything said here has been said before and sometimes with more cogency by doctors themselves. The final sentence of the book declares "... we can try to achieve a better understanding of ourselves through a liberation of instincts long dormant, and where necessary a change in our life-style". That seems sensible enough perhaps, but how on earth do we bring it about? It is in not answering that Inglis disappoints. There is not the revelation I had hoped for. Postgraduate Department, Southampton General Hospital, Southampton SO9 4XY
PHILIP RHODES