- Email: [email protected]
The good old days
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Nyongo A, Gichangi P, Temmerman M, Ndinya-Achola JO. HIV infection as a risk factor for chorioamnionitis in preterm birth. Int Conf AIDS 1992; 8 (2): B165 (abstr no PoB 3469). Minkoff H, Burns DN, Landesman S, et al. The relationship of the duration of ruptured membranes to vertical transmission of human immunodeficiency virus. Am J Obstet Gynecol 1995; 173: 585–89. Mofenson LM. Interacton between timing of perinatal human immunodeficiency virus infection and the design of preventive and therapeutic interventions. Acta Paediatr Suppl 1997; 491: 1–9. Mundy DC, Schinazi RF, Gerber AR, Nahmias AJ, Randall HW Jr. Human immunodeficiency virus isolated from amniotic fluid. Lancet 1987; ii: 549–60. Rasheed S, Li Z, Xu D, Kovacs A. Presence of cell-free human immunodefiency virus in cervicovaginal secretions is independent of viral load in the blood of human immunodeficiency virus-infected women. Am J Obstet Gynecol 1996; 175: 122–29. Andrews WW, Goldenberg RL, Hauth JC. Preterm labor: emerging role of genital tract infections. Infect Agents Dis 1995; 4: 196–211. Melendez-Guerrero L, Holmes R, Backe E, et al. In vitro infection of Hofbauer cells with a monocyte-tropic strain of HIV-1. Trophoblast Res 1994; 8: 33–45. Goldenberg RL, Iams JD, Mercer BM, Meis PJ, Moawad AH, Copper RL. The preterm prediction study: fetal fibronectin, bacterial vaginosis and peripartum infection. Obstet Gynecol 1996; 87: 656–60. Hauth JC, Goldenberg RL, Andrews WW, DuBard MB, Cooper RL. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. N Engl J Med 1995; 333: 1732–36. Norman K, Pattinson RC, de Souza J, de Jong P, Moller G, Kirsten G. Ampicillin and metronidazole treatment in preterm labour: a multicentre, randomised controlled trial. Br J Obstet Gynecol 1994; 101: 404–08.
15 Goldenberg RL, Andrews WW, Yuan AA, MacKay T, St Louis M. Sexually transmitted diseases and adverse outcomes of pregnancy. Clin Perinatol 1997; 24: 23–41. 16 Fiscella K. Racial disparities in preterm births. The role of urogenital infections. Public Health Rep 1996; 111: 104–13. 17 Taha TE, Kumwenda N, Liomba G, et al. Heterosexual and perinatal transmission of HIV-1: associations with bacterial vaginosis (BV). XIth World AIDS Conference, Geneva, Switzerland, July, 1998: (abstr 527). 18 Biggars RJ, Miotti PG, Taha TE, et al. Perinatal intervention trial in Africa: effect of a birth canal cleansing intervention to prevent HIV transmission. Lancet 1996; 347: 1647–50. 19 Mercer BM, Miodovnik M, Thurnau GR, et al. Antibiotic therapy for the reduction of morbidity and mortality after preterm premature rupture of the membranes. JAMA 1997; 278: 989–95. 20 Mandelbrot L, Le Chenadec J, Berrebi A, et al. Perinatal HIV-1 transmission interaction between zidovudine prophylaxis and mode of delivery in the French perinatal (chart). 21 Schaefer A, Kriese K, Lauper U, et al. Influence of cesarean section before parturition and antiretroviral prophylaxis on the materno-fetal transmission of HIV. XIIth World AIDS Conference, Geneva, Switzerland, July, 1998: (abstr 12466). 22 Schafer AP. Cytokine network during pregnancy and consequences for HIV transmission. Int Conf AIDS 1993; 9: 91. 23 Fazely F, Sharma PL, Fratazzi C, et al. Simian immunodeficency virus infection via amniotic fluid: a model to study fetal immunopathogenesis and prophylaxis. J Acquir Immune Defic Syndr 1993; 6: 107–14. 24 Mortality and Morbidity World Report. Administration of zidovudine during late pregnancy and delivery to prevent perinatal HIV transmission—Thailand, 1996–1998. JAMA 1998; 279: 1061–62. 25 Mansergh G, Haddix AC, Steketee RW, et al. Cost-effectiveness of short-course zidovudine to prevent perinatal HIV type 1 infection in a sub-Saharan African developing country setting. JAMA 1996; 276: 139–45.
Viewpoint
The good old days
Joseph Herman Nostalgia, defined as “ . . . a longing for something far away or long ago”,1 permeates our attempts to redefine the relationship between patient and doctor in the light of societal evolution and recent scientific developments.2 This longing suggests dissatisfaction with the present and, perhaps, a conviction that things used to be better. “The ancient, very successful, physician-patient relationship requires many adjustments and alterations, and there now prevails a new basis for interaction . . .”.3 From where does the nostalgia arise and on what do we predicate our assumption that, in the good old days, we were less harried and more caring? A prime source of knowledge about yesterday is memory—a faculty with many failings, especially among those of us who have arrived at the age of benign forgetfulness. Do I really remember what it was like to study medicine 40 years ago and to begin practising it shortly thereafter? To what extent can I depend on my recollection of those “happy” days, distinguished, so Lancet 1998; 352: 1930–31 Assia Community Health Centre, Netivot, Israel Correspondence to: 24 Megadim Street, Y’fe Nof 96185, Jerusalem, Israel (J Herman MD)
1930
many believe, by more compassionate and empathetic physicians than those of today? On the one hand, so much has improved since then with respect to diagnosis, prevention, and therapy, that practice has changed almost beyond recognition. We can now prolong the lives of patients with chronic congestive heart failure4 and diagnose lesions of the retroperitoneum, formerly invisible, by means of ultrasonography. Additionally, we have laparoscopic surgery, hip nailing and replacement, anaesthetic techniques enabling lengthy and complicated operations, as well as immunisations not dreamt of a generation ago. On the other hand, it is important to remember that we applied the means at our disposal way back then with enthusiasm, never feeling either impotent or nihilistic when it came to prescribing treatment. There are those who speak of a “. . . relegating of individual human values to a second order of priority in relation to applying the advances of modern, scientific, technologic medicine”.5 Again, we are told that “Our technical advances, together with the accompanying changes in our social structure, confront us with a variety of problems which continue to challenge our former and accustomed ways of thinking”.6 Both statements suggest a THE LANCET • Vol 352 • December 12, 1998
VIEWPOINT
kind of “either or”, advanced technology and highly skilled operators versus compassionate, empathetic, altruistic physicians. Our calling is not a scientific one, although it uses science as one of its instruments; doctors are not servants of nature, the human race, or life but of the individual.7 Thus, there is no such thing as “scientific, technologic medicine”, only a helping profession employing and deploying mechanical means for the benefit of suffering humanity. In 1927, Francis Peabody wrote: “The secret of the care of the patient is in caring for the patient”.8 This suggests that 70 years ago, when a radiographic apparatus and an extremely unwieldy electrocardiographic machine were about as technically advanced as you could get, the question of compassion versus technology was very much in the air. Had all physicians been caring and humane at that time, there would have been no need for Peabody’s dictum. That humane medicine is, somehow, a function of an unhurried pace and a low-tech approach has been pointed out.9 Moreover, it has been suggested that empathy is a natural endowment for most of us, but that we tend to lose it along the way as we are socialised and professionalised in the calling of medicine: “As I know them, college students start out with much empathy and genuine love—a real desire to help other people. In medical school, however, they learn to mask their feelings, or worse, to deny them. They learn detachment and equanimity”.10 But might not the process also operate in the opposite direction? Students and doctors in training are kept anxious and uptight by their lack of experience and their fear of missing an important, treatable condition. With the acquisition of a certain amount of self-assurance, matters become more relaxed between them and their patients, and compassion can emerge “from under” the differential diagnosis. Both endogenous and exogenous factors have been noted in our loss of humaneness and altruism,2 whether at the personal or the historical level. The exogenous kind is linked to societal changes: managed care, a proclivity to litigation, the increasing cost of medical education, living under the threat that future rewards will be wiped out by economic, military, or environmental calamity.5,11,12 “Perhaps people now feel a more urgent need for immediate gratification because any other goal seems increasingly evanescent.”12 Endogenous factors contributing to the profession’s malaise, nostalgia, and maladaptation include changes in physician motivation away from service to one’s god and fellow-man and towards an emphasis on rights as opposed to duties.2 In addition, we now experience the exhilarating “fix” of power to cure and so derive less satisfaction from extending comfort and reassurance: “Obsessed with the miracles of modern medicine and technology, hynotized by their own hype that medicine can cure all, physicians have much less patience and time
THE LANCET • Vol 352 • December 12, 1998
for the patient who ‘does not respond’, who cannot, or ‘will not’ be cured”.2 Finally, we have become overly dependent for gratification on popularity and patient adulation: “The public climate, particularly the media, has not been charitable to the medical profession of late, and many physicians, desperate for positive feedback and reinforcement from external sources and dependent on this praise, are frustrated”.2 Several basic facts must be considered when the evolution of the physician-patient relationship is discussed. First, changes in society and scientific developments are frequent sources of strain. Second, our perception that doctors were more compassionate, empathetic, and caring when there was little they could do to combat disease is almost certainly fallacious since, as far back as 70 years ago, they were being preached to about what it means to “care for” the patient. Third, even though to us it may seem that the physicians of bygone days were therapeutically impotent, a perusal of older medical textbooks reveals no lack of enthusiasm for treatment.13 Fourth, our recall of the degree to which practice was humane, when, the more senior among us set out on their careers some 40 years ago, is notoriously untrustworthy and there is no solid evidence that we should be nostalgic for yesterday. Last, nostalgia implies dissatisfaction with the present, something that has more to do with the process of ageing than with demonstrable differences between “then” and “now”. Recognising its origins is important, since we cannot, in any circumstances, stem the tide of change in the societies in which we live.
References 1 2 3 4 5
6
7 8 9 10 11
12 13
Webster’s New Twentieth Century Dictionary. 2nd edn. USA: Collins World 1978. Glick SM. From Arrowsmith to The House of God, or “Why Now?” Am J Med 1990; 88: 449–51. Angrist AA. Introduction to symposium on humanism and medical ethics. NY State J Med 1977; 88: 449–51. Drugs for chronic heart failure. Med Lett Drugs Ther 1996; 38: 92–94. Naughton J. Medical ethics, humanism, and preparation of modern physician. In: Angrist AA, ed. Symposium: humanism and medical ethics. NY State J Med 1977; 77: 1448–51. Nordlicht S. Teaching humanity-oriented ethics. In: Angrist AA, ed. Symposium: humanism and medical ethics. NY State J Med 1977; 77: 1452–54. Fox T. Purposes of medicine. Lancet 1965; ii: 801–05. Peabody FW. Quoted in: Fox T. Purposes of medicine. Lancet 1965; ii: 801–05. Volpintesta EJ. Empathy: can it be taught? Ann Intern Med 1992; 117: 700. Spiro H. What is empathy and can it be taught? Ann Intern Med 1992; 116: 843–46. Graef I. Decline of altruism in medical care. In: Angrist AA, ed. Symposium: humanism and medical ethics. NY State J Med 1977; 77: 1454–56. Dubovsky SL. Coping with entitlement in medical education. N Engl J Med 1986; 315: 1672–74. Herman J. Therapeutic nihilism? Isr J Med Sci 1996; 32: 259–64.
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Nyongo A, Gichangi P, Temmerman M, Ndinya-Achola JO. HIV infection as a risk factor for chorioamnionitis in preterm birth. Int Conf AIDS 1992; 8 (2): B165 (abstr no PoB 3469). Minkoff H, Burns DN, Landesman S, et al. The relationship of the duration of ruptured membranes to vertical transmission of human immunodeficiency virus. Am J Obstet Gynecol 1995; 173: 585–89. Mofenson LM. Interacton between timing of perinatal human immunodeficiency virus infection and the design of preventive and therapeutic interventions. Acta Paediatr Suppl 1997; 491: 1–9. Mundy DC, Schinazi RF, Gerber AR, Nahmias AJ, Randall HW Jr. Human immunodeficiency virus isolated from amniotic fluid. Lancet 1987; ii: 549–60. Rasheed S, Li Z, Xu D, Kovacs A. Presence of cell-free human immunodefiency virus in cervicovaginal secretions is independent of viral load in the blood of human immunodeficiency virus-infected women. Am J Obstet Gynecol 1996; 175: 122–29. Andrews WW, Goldenberg RL, Hauth JC. Preterm labor: emerging role of genital tract infections. Infect Agents Dis 1995; 4: 196–211. Melendez-Guerrero L, Holmes R, Backe E, et al. In vitro infection of Hofbauer cells with a monocyte-tropic strain of HIV-1. Trophoblast Res 1994; 8: 33–45. Goldenberg RL, Iams JD, Mercer BM, Meis PJ, Moawad AH, Copper RL. The preterm prediction study: fetal fibronectin, bacterial vaginosis and peripartum infection. Obstet Gynecol 1996; 87: 656–60. Hauth JC, Goldenberg RL, Andrews WW, DuBard MB, Cooper RL. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. N Engl J Med 1995; 333: 1732–36. Norman K, Pattinson RC, de Souza J, de Jong P, Moller G, Kirsten G. Ampicillin and metronidazole treatment in preterm labour: a multicentre, randomised controlled trial. Br J Obstet Gynecol 1994; 101: 404–08.
15 Goldenberg RL, Andrews WW, Yuan AA, MacKay T, St Louis M. Sexually transmitted diseases and adverse outcomes of pregnancy. Clin Perinatol 1997; 24: 23–41. 16 Fiscella K. Racial disparities in preterm births. The role of urogenital infections. Public Health Rep 1996; 111: 104–13. 17 Taha TE, Kumwenda N, Liomba G, et al. Heterosexual and perinatal transmission of HIV-1: associations with bacterial vaginosis (BV). XIth World AIDS Conference, Geneva, Switzerland, July, 1998: (abstr 527). 18 Biggars RJ, Miotti PG, Taha TE, et al. Perinatal intervention trial in Africa: effect of a birth canal cleansing intervention to prevent HIV transmission. Lancet 1996; 347: 1647–50. 19 Mercer BM, Miodovnik M, Thurnau GR, et al. Antibiotic therapy for the reduction of morbidity and mortality after preterm premature rupture of the membranes. JAMA 1997; 278: 989–95. 20 Mandelbrot L, Le Chenadec J, Berrebi A, et al. Perinatal HIV-1 transmission interaction between zidovudine prophylaxis and mode of delivery in the French perinatal (chart). 21 Schaefer A, Kriese K, Lauper U, et al. Influence of cesarean section before parturition and antiretroviral prophylaxis on the materno-fetal transmission of HIV. XIIth World AIDS Conference, Geneva, Switzerland, July, 1998: (abstr 12466). 22 Schafer AP. Cytokine network during pregnancy and consequences for HIV transmission. Int Conf AIDS 1993; 9: 91. 23 Fazely F, Sharma PL, Fratazzi C, et al. Simian immunodeficency virus infection via amniotic fluid: a model to study fetal immunopathogenesis and prophylaxis. J Acquir Immune Defic Syndr 1993; 6: 107–14. 24 Mortality and Morbidity World Report. Administration of zidovudine during late pregnancy and delivery to prevent perinatal HIV transmission—Thailand, 1996–1998. JAMA 1998; 279: 1061–62. 25 Mansergh G, Haddix AC, Steketee RW, et al. Cost-effectiveness of short-course zidovudine to prevent perinatal HIV type 1 infection in a sub-Saharan African developing country setting. JAMA 1996; 276: 139–45.
Viewpoint
The good old days
Joseph Herman Nostalgia, defined as “ . . . a longing for something far away or long ago”,1 permeates our attempts to redefine the relationship between patient and doctor in the light of societal evolution and recent scientific developments.2 This longing suggests dissatisfaction with the present and, perhaps, a conviction that things used to be better. “The ancient, very successful, physician-patient relationship requires many adjustments and alterations, and there now prevails a new basis for interaction . . .”.3 From where does the nostalgia arise and on what do we predicate our assumption that, in the good old days, we were less harried and more caring? A prime source of knowledge about yesterday is memory—a faculty with many failings, especially among those of us who have arrived at the age of benign forgetfulness. Do I really remember what it was like to study medicine 40 years ago and to begin practising it shortly thereafter? To what extent can I depend on my recollection of those “happy” days, distinguished, so Lancet 1998; 352: 1930–31 Assia Community Health Centre, Netivot, Israel Correspondence to: 24 Megadim Street, Y’fe Nof 96185, Jerusalem, Israel (J Herman MD)
1930
many believe, by more compassionate and empathetic physicians than those of today? On the one hand, so much has improved since then with respect to diagnosis, prevention, and therapy, that practice has changed almost beyond recognition. We can now prolong the lives of patients with chronic congestive heart failure4 and diagnose lesions of the retroperitoneum, formerly invisible, by means of ultrasonography. Additionally, we have laparoscopic surgery, hip nailing and replacement, anaesthetic techniques enabling lengthy and complicated operations, as well as immunisations not dreamt of a generation ago. On the other hand, it is important to remember that we applied the means at our disposal way back then with enthusiasm, never feeling either impotent or nihilistic when it came to prescribing treatment. There are those who speak of a “. . . relegating of individual human values to a second order of priority in relation to applying the advances of modern, scientific, technologic medicine”.5 Again, we are told that “Our technical advances, together with the accompanying changes in our social structure, confront us with a variety of problems which continue to challenge our former and accustomed ways of thinking”.6 Both statements suggest a THE LANCET • Vol 352 • December 12, 1998
VIEWPOINT
kind of “either or”, advanced technology and highly skilled operators versus compassionate, empathetic, altruistic physicians. Our calling is not a scientific one, although it uses science as one of its instruments; doctors are not servants of nature, the human race, or life but of the individual.7 Thus, there is no such thing as “scientific, technologic medicine”, only a helping profession employing and deploying mechanical means for the benefit of suffering humanity. In 1927, Francis Peabody wrote: “The secret of the care of the patient is in caring for the patient”.8 This suggests that 70 years ago, when a radiographic apparatus and an extremely unwieldy electrocardiographic machine were about as technically advanced as you could get, the question of compassion versus technology was very much in the air. Had all physicians been caring and humane at that time, there would have been no need for Peabody’s dictum. That humane medicine is, somehow, a function of an unhurried pace and a low-tech approach has been pointed out.9 Moreover, it has been suggested that empathy is a natural endowment for most of us, but that we tend to lose it along the way as we are socialised and professionalised in the calling of medicine: “As I know them, college students start out with much empathy and genuine love—a real desire to help other people. In medical school, however, they learn to mask their feelings, or worse, to deny them. They learn detachment and equanimity”.10 But might not the process also operate in the opposite direction? Students and doctors in training are kept anxious and uptight by their lack of experience and their fear of missing an important, treatable condition. With the acquisition of a certain amount of self-assurance, matters become more relaxed between them and their patients, and compassion can emerge “from under” the differential diagnosis. Both endogenous and exogenous factors have been noted in our loss of humaneness and altruism,2 whether at the personal or the historical level. The exogenous kind is linked to societal changes: managed care, a proclivity to litigation, the increasing cost of medical education, living under the threat that future rewards will be wiped out by economic, military, or environmental calamity.5,11,12 “Perhaps people now feel a more urgent need for immediate gratification because any other goal seems increasingly evanescent.”12 Endogenous factors contributing to the profession’s malaise, nostalgia, and maladaptation include changes in physician motivation away from service to one’s god and fellow-man and towards an emphasis on rights as opposed to duties.2 In addition, we now experience the exhilarating “fix” of power to cure and so derive less satisfaction from extending comfort and reassurance: “Obsessed with the miracles of modern medicine and technology, hynotized by their own hype that medicine can cure all, physicians have much less patience and time
THE LANCET • Vol 352 • December 12, 1998
for the patient who ‘does not respond’, who cannot, or ‘will not’ be cured”.2 Finally, we have become overly dependent for gratification on popularity and patient adulation: “The public climate, particularly the media, has not been charitable to the medical profession of late, and many physicians, desperate for positive feedback and reinforcement from external sources and dependent on this praise, are frustrated”.2 Several basic facts must be considered when the evolution of the physician-patient relationship is discussed. First, changes in society and scientific developments are frequent sources of strain. Second, our perception that doctors were more compassionate, empathetic, and caring when there was little they could do to combat disease is almost certainly fallacious since, as far back as 70 years ago, they were being preached to about what it means to “care for” the patient. Third, even though to us it may seem that the physicians of bygone days were therapeutically impotent, a perusal of older medical textbooks reveals no lack of enthusiasm for treatment.13 Fourth, our recall of the degree to which practice was humane, when, the more senior among us set out on their careers some 40 years ago, is notoriously untrustworthy and there is no solid evidence that we should be nostalgic for yesterday. Last, nostalgia implies dissatisfaction with the present, something that has more to do with the process of ageing than with demonstrable differences between “then” and “now”. Recognising its origins is important, since we cannot, in any circumstances, stem the tide of change in the societies in which we live.
References 1 2 3 4 5
6
7 8 9 10 11
12 13
Webster’s New Twentieth Century Dictionary. 2nd edn. USA: Collins World 1978. Glick SM. From Arrowsmith to The House of God, or “Why Now?” Am J Med 1990; 88: 449–51. Angrist AA. Introduction to symposium on humanism and medical ethics. NY State J Med 1977; 88: 449–51. Drugs for chronic heart failure. Med Lett Drugs Ther 1996; 38: 92–94. Naughton J. Medical ethics, humanism, and preparation of modern physician. In: Angrist AA, ed. Symposium: humanism and medical ethics. NY State J Med 1977; 77: 1448–51. Nordlicht S. Teaching humanity-oriented ethics. In: Angrist AA, ed. Symposium: humanism and medical ethics. NY State J Med 1977; 77: 1452–54. Fox T. Purposes of medicine. Lancet 1965; ii: 801–05. Peabody FW. Quoted in: Fox T. Purposes of medicine. Lancet 1965; ii: 801–05. Volpintesta EJ. Empathy: can it be taught? Ann Intern Med 1992; 117: 700. Spiro H. What is empathy and can it be taught? Ann Intern Med 1992; 116: 843–46. Graef I. Decline of altruism in medical care. In: Angrist AA, ed. Symposium: humanism and medical ethics. NY State J Med 1977; 77: 1454–56. Dubovsky SL. Coping with entitlement in medical education. N Engl J Med 1986; 315: 1672–74. Herman J. Therapeutic nihilism? Isr J Med Sci 1996; 32: 259–64.
1931