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Death of the personal doctor
THE LANCET
Essay
Death of the personal doctor James McCormick In the past 30 years the doctor as a father figure has become unfashionable and derided, and is even seen as unethical. Yet the doctor as plumber denies some of the fundamental needs of those who are, or believe themselves to be, sick. For human beings pain requires an explanation: pain carries reminders of our mortality. Illness has an emotional component that leaking cisterns do not share.1 The experience of illness with its threat to our survival reduces us all to childlike dependence. We need somebody to take away both the pain of disease and the pain of uncertainty. That somebody must be invested with trust: trust to do what is best for us irrespective of other competing claims on time and energy. The British Medical Journal has in recent years published contributions under the general title Personal View. Many of these are physicians’ descriptions of their own experience of illness. Almost without exception these accounts are not critical of the quality of technical care, but catalogue failures of communication, understanding, and empathy. It is 35 years since Theodore Fox published his paper The personal doctor.2 In this paper, and subsequently in his Harveian Oration The purposes of medicine, he argued that everybody needed a personal doctor.3 “More and more, as the years go by, the person who devises and performs new miracles is going to be concerned with things rather than people; and the growth of scientific medicine makes it imperative that he should be balanced by someone who is concerned with people rather than things. So that he shall get what he needs, and shall not get what he does not need, every patient in hospital—medical or surgical or anything else—should in my opinion be looked after by a general physician.”3 The truly general physician has disappeared from our hospitals. With increasing specialisation and the growth of knowledge there has been a reluctance on the part of hospital consultants to take responsibility for anything that does not seem to lie within the area of their special competence. As a result, care of the patient is divided between several physicians, and it is sometimes difficult to decide whose is the ultimate responsibility. Furthermore, in general practice the contract is between a patient and a named, and usually known, doctor, whereas for most people who attend hospital the contract is between the patient and the institution. Patients, outside the private sector, attend St Elsewhere’s, rather than Mr X or Dr Y. Sir Theodore acknowledged that general practice might be the source of the wise general physician who can be both advocate and protector. In the not too distant past general practice often provided personal and continuing
Lancet 1996; 348: 667–68 Department of Community Health and General Practice, University of Dublin, 199 Pearse Street, Dublin 2, Ireland (J McCormick FRCGP )
Vol 348 • September 7, 1996
care; it was continuing care that allowed the possibility of knowing the person who has the disease. There is no doubt that, although the possibility of continuing care remains, it has been eroded by the growth of group practices, duty rotas (especially for work out of hours), and mobility within society. It is also threatened by the growth of the team. Sir Theodore expressed the fear that, “the particular object of his [the doctor’s] independent existence may be defeated if he leaves all dressings to the nurse, sympathy to the receptionist, messages to the secretary, and the solution of home problems to the social worker . . . if somebody else is to do all the small things for the patient under the doctor’s distant supervision, personal contact will be reduced to a minimum”2—contact that is the necessary prerequisite for knowing the person and becoming an advocate for their concerns. The erosion of personal doctoring has altered the relationship between patient and doctor. If the doctor is nothing more than a plumber who is available 24 hours a day and paid for by the state, patients, as consumers, feel they have a right to service on demand. Their experience is of impersonal medicine. Doctors who do not know the person who is asking for a visit during the night are reduced to seeing the justification for the call in mechanistic terms. That bond of mutual trust and respect which at one time rewarded both patient and doctor has often, but happily not always, been eroded to the point of disappearance. Illness causes a regression towards childlike dependence. The advocates of patient autonomy tend sometimes to deny this reality. There is a difference between acute life-threatening disease and chronic conditions. In the acute crisis there is no option other than to have faith that physicians and surgeons will do the best they can. In the increasingly common circumstance of chronic and incurable disease the exercise of some degree of patient autonomy is an ethical imperative. However, the balance of power between patient and physician is, a priori, unequal. The doctor not only possesses knowledge and expertise that is not shared, but also controls access to drugs and to care. No matter to what extent information is provided, it is the doctor who decides its nature and who will, by his or her advice, almost always determine the outcome. For this reason, trust in the doctor is as important in the case of chronic disease as it is in acute life-threatening emergencies. “The patient may well be safer with a physician who is naturally wise rather than with one who is artifically learned”, said Sir Theordore. It is unusual these days for anyone to extol the virtues of wise judgment. J K Galbraith has remarked that the denigration of value judgment is one of the devices by which the scientific establishment maintains its misconceptions, which is an aphorism marred by the tautologous addition of value to judgment. Judgment and wisdom (its bedfellow), are concerned with adding weight to the imponderable, with adding values to the unmeasurable. 667
THE LANCET
One occasionally reads obituaries of physicians, and surgeons, whose careers at first sight seem unremarkable, but who were regarded by their colleagues as physician’s physicians. It is certain that such doctors were valued more for their wisdom than for their learning. They were chosen because of their ability to distinguish between what could, and what should, be done. For good reasons, reducing the possibility of error and increasing the probability of cost-effective action, there has been a recent flood of guidelines. Guidelines derive from population studies and are not always applicable to the unique person who decides to consult. All might be well if guidelines were securely based and if they were perceived as giving advice rather than mandatory instruction. Unfortunately many guidelines are insecurely based, and doctors, sometimes fearing medico-legal consequences, are motivated towards slavish adherence to them.4 Inappropriate enthusiasm for patient autonomy, the growth of teams and delegated responsibility, and preoccupation with guidelines, all threaten recognition of the individual. In many instances knowing the person who
has the disease is as important as knowing the disease that person has. Those who are ill still need a personal doctor whom they may safely trust. Given a choice between a competent plumber and an imcompetent father figure there is little doubt what commonsense would advise. On the other hand, the gradual and now considerable erosion of the notion of a personal doctor who has knowledge of patients as people and who has earned their trust has diminished; this is the cause of much that is bad in medicine. I thank Biddy, my wife, Tom O’Dowd, and Vera Capcova Srabanek for cogent and constructive criticism.
References 1 2 3 4
McCormick JS. The doctor: father figure or plumber. London: Croom Helm, 1979. Fox TF. The personal doctor. Lancet 1960; ii: 743–60. Fox TF. The purposes of medicine. Lancet 1965; ii: 801–05. McCormick JS. Management guidelines in essential hypertension: a critique with particular reference to the elderly. Fam Doctor (WONCA) 1994; 4: 14–15.
Department of poetry
THE BALL I wish—I wish— I wish they hadn’t told him Like that—or at all. Hope taken away Drains the life-blood, Stills the heart, Quenches light from the day. If they had known him As we did, long long ago When we were young, and he Smallest of all, Jumping to catch the ball ’Til smitten with guilt At his tear-filled eyes We threw it to him. If they had known him As we did, when he was small, They might, out of pity Have thrown him the ball.
Eithne Murphy Ranelagh, Dublin, Ireland
Looking through
Lizzie Foster
668
Vol 348 • September 7, 1996
Essay
Death of the personal doctor James McCormick In the past 30 years the doctor as a father figure has become unfashionable and derided, and is even seen as unethical. Yet the doctor as plumber denies some of the fundamental needs of those who are, or believe themselves to be, sick. For human beings pain requires an explanation: pain carries reminders of our mortality. Illness has an emotional component that leaking cisterns do not share.1 The experience of illness with its threat to our survival reduces us all to childlike dependence. We need somebody to take away both the pain of disease and the pain of uncertainty. That somebody must be invested with trust: trust to do what is best for us irrespective of other competing claims on time and energy. The British Medical Journal has in recent years published contributions under the general title Personal View. Many of these are physicians’ descriptions of their own experience of illness. Almost without exception these accounts are not critical of the quality of technical care, but catalogue failures of communication, understanding, and empathy. It is 35 years since Theodore Fox published his paper The personal doctor.2 In this paper, and subsequently in his Harveian Oration The purposes of medicine, he argued that everybody needed a personal doctor.3 “More and more, as the years go by, the person who devises and performs new miracles is going to be concerned with things rather than people; and the growth of scientific medicine makes it imperative that he should be balanced by someone who is concerned with people rather than things. So that he shall get what he needs, and shall not get what he does not need, every patient in hospital—medical or surgical or anything else—should in my opinion be looked after by a general physician.”3 The truly general physician has disappeared from our hospitals. With increasing specialisation and the growth of knowledge there has been a reluctance on the part of hospital consultants to take responsibility for anything that does not seem to lie within the area of their special competence. As a result, care of the patient is divided between several physicians, and it is sometimes difficult to decide whose is the ultimate responsibility. Furthermore, in general practice the contract is between a patient and a named, and usually known, doctor, whereas for most people who attend hospital the contract is between the patient and the institution. Patients, outside the private sector, attend St Elsewhere’s, rather than Mr X or Dr Y. Sir Theodore acknowledged that general practice might be the source of the wise general physician who can be both advocate and protector. In the not too distant past general practice often provided personal and continuing
Lancet 1996; 348: 667–68 Department of Community Health and General Practice, University of Dublin, 199 Pearse Street, Dublin 2, Ireland (J McCormick FRCGP )
Vol 348 • September 7, 1996
care; it was continuing care that allowed the possibility of knowing the person who has the disease. There is no doubt that, although the possibility of continuing care remains, it has been eroded by the growth of group practices, duty rotas (especially for work out of hours), and mobility within society. It is also threatened by the growth of the team. Sir Theodore expressed the fear that, “the particular object of his [the doctor’s] independent existence may be defeated if he leaves all dressings to the nurse, sympathy to the receptionist, messages to the secretary, and the solution of home problems to the social worker . . . if somebody else is to do all the small things for the patient under the doctor’s distant supervision, personal contact will be reduced to a minimum”2—contact that is the necessary prerequisite for knowing the person and becoming an advocate for their concerns. The erosion of personal doctoring has altered the relationship between patient and doctor. If the doctor is nothing more than a plumber who is available 24 hours a day and paid for by the state, patients, as consumers, feel they have a right to service on demand. Their experience is of impersonal medicine. Doctors who do not know the person who is asking for a visit during the night are reduced to seeing the justification for the call in mechanistic terms. That bond of mutual trust and respect which at one time rewarded both patient and doctor has often, but happily not always, been eroded to the point of disappearance. Illness causes a regression towards childlike dependence. The advocates of patient autonomy tend sometimes to deny this reality. There is a difference between acute life-threatening disease and chronic conditions. In the acute crisis there is no option other than to have faith that physicians and surgeons will do the best they can. In the increasingly common circumstance of chronic and incurable disease the exercise of some degree of patient autonomy is an ethical imperative. However, the balance of power between patient and physician is, a priori, unequal. The doctor not only possesses knowledge and expertise that is not shared, but also controls access to drugs and to care. No matter to what extent information is provided, it is the doctor who decides its nature and who will, by his or her advice, almost always determine the outcome. For this reason, trust in the doctor is as important in the case of chronic disease as it is in acute life-threatening emergencies. “The patient may well be safer with a physician who is naturally wise rather than with one who is artifically learned”, said Sir Theordore. It is unusual these days for anyone to extol the virtues of wise judgment. J K Galbraith has remarked that the denigration of value judgment is one of the devices by which the scientific establishment maintains its misconceptions, which is an aphorism marred by the tautologous addition of value to judgment. Judgment and wisdom (its bedfellow), are concerned with adding weight to the imponderable, with adding values to the unmeasurable. 667
THE LANCET
One occasionally reads obituaries of physicians, and surgeons, whose careers at first sight seem unremarkable, but who were regarded by their colleagues as physician’s physicians. It is certain that such doctors were valued more for their wisdom than for their learning. They were chosen because of their ability to distinguish between what could, and what should, be done. For good reasons, reducing the possibility of error and increasing the probability of cost-effective action, there has been a recent flood of guidelines. Guidelines derive from population studies and are not always applicable to the unique person who decides to consult. All might be well if guidelines were securely based and if they were perceived as giving advice rather than mandatory instruction. Unfortunately many guidelines are insecurely based, and doctors, sometimes fearing medico-legal consequences, are motivated towards slavish adherence to them.4 Inappropriate enthusiasm for patient autonomy, the growth of teams and delegated responsibility, and preoccupation with guidelines, all threaten recognition of the individual. In many instances knowing the person who
has the disease is as important as knowing the disease that person has. Those who are ill still need a personal doctor whom they may safely trust. Given a choice between a competent plumber and an imcompetent father figure there is little doubt what commonsense would advise. On the other hand, the gradual and now considerable erosion of the notion of a personal doctor who has knowledge of patients as people and who has earned their trust has diminished; this is the cause of much that is bad in medicine. I thank Biddy, my wife, Tom O’Dowd, and Vera Capcova Srabanek for cogent and constructive criticism.
References 1 2 3 4
McCormick JS. The doctor: father figure or plumber. London: Croom Helm, 1979. Fox TF. The personal doctor. Lancet 1960; ii: 743–60. Fox TF. The purposes of medicine. Lancet 1965; ii: 801–05. McCormick JS. Management guidelines in essential hypertension: a critique with particular reference to the elderly. Fam Doctor (WONCA) 1994; 4: 14–15.
Department of poetry
THE BALL I wish—I wish— I wish they hadn’t told him Like that—or at all. Hope taken away Drains the life-blood, Stills the heart, Quenches light from the day. If they had known him As we did, long long ago When we were young, and he Smallest of all, Jumping to catch the ball ’Til smitten with guilt At his tear-filled eyes We threw it to him. If they had known him As we did, when he was small, They might, out of pity Have thrown him the ball.
Eithne Murphy Ranelagh, Dublin, Ireland
Looking through
Lizzie Foster
668
Vol 348 • September 7, 1996