The Art of Medicine & the Dinosaurs amongst Us…

At the Dawn of A New Age

Dr David KL Quek

dquek@pc.jaring.my

The Human Genome Unravelled, yet…

This year 2000 will likely be remembered as that benchmark revolution for medical history where medicine and health care takes on another quantum leap into yet another dimension. We have been informed that the first draft of the Human Genome has just been mapped. Quite possibly, the practice of medicine and health care as we know it today will likely be changed forever. With the ever-newer technological discoveries, we stand poised on the cusp of historic and momentous events, which will continually re-shape our practices and possibly our lives, hitherto unimaginable.

These wondrous medical advances are not just limited to those concerning genetically-related paradigms, but also many others such as key-hole, robotic and micro-surgical techniques, nano-technologies, etc. Yet despite all these stunning advances, mankind and medical science has not really learnt to control the more primitive forces of ongoing deadly or disabling perennial pandemics, the sporadic jolts of newly emerging infections, nor the chronically debilitating and ultimately fatal cancers.

AIDS, Malaria, tuberculosis, childhood ailments (poliomyelitis, typhoid, measles, diphtheria, tetanus, cholera, infective diarrhoeas, acute respiratory infections, etc.), and chronic illness such as cardiovascular diseases, strokes, cancers, even neuropsychiatric disorders continue to plaque us into the new century with a growing vengeance. Many of these are potentially eradicable, but the world as we know it now, has no united will or clout to bring this about.

WHO has been very vocal of late, on the need for a new vision and determination to see the global elimination of most if not all of these infections. WHO stressed the need for a more concerted effort of achieving 100% penetration of vaccination programs, particularly in the poorest most endemic countries. Clearly, public health measures must continue to progress in tandem with the stupendously advancing medical technologies – whether preventive, diagnostic or therapeutic measures.

In many ways clever uses of modern techniques can help spearhead newer approaches to contain the spread of epidemic infections. For example, a genetically-modified ‘green’ mosquito has recently been produced (using gene-insertion techniques) which is said to be resistant to the infestation with the plasmodium parasite. When introduced into the wild, this ‘green’ mosquito might ultimately replace the native species completely, and obliterate malaria by ridding it of its most ubiquitous intermediate vector. However, this is still early days yet, and it will be some years before any positive results can be known for sure.

More Empathy Required…

While we might all be awestricken by the Human Genome project and how it could potentially change our lives and our medical practices, more mundane day-to-day issues remain, which will increasingly impact on the medical profession.

While many doctors these days, are increasingly becoming more and more technologically minded, there have also been increasing complaints that we have become less and less personal. Many of our patients are becoming more and more disenchanted with the perceived lack of proper communication, leading inevitably to more misunderstanding and a greater likelihood for adversarial challenges and malpractice claims. The empathetic physician appears to have become near-extinct, in place of which, is the technical wizard who appears ever so ready to introduce whatever, tubes or scopes or mini-surgical probes into the human body for diagnosis or therapy. The pragmatic, the skilled but brash man-of-few-words technician appears to have replaced the physician who previously would have been an intimate friend or confidant.

Undoubtedly there is still a great deal of paternalistic mindset among many physicians, who have the mistaken but disdainful concept that most of their patients out there are by and large ignoramuses, who could not understand much anyway. Sadly, these days we would be foolish indeed to continue with this contemptuous preconception, at our own peril.

Information empowerment of the public is already upon us and will daily grow ever stronger. The World Wide Web and the Internet has put paid our hitherto monopolistic control of whatever medical information that we thought we had to ourselves alone. This information and knowledge largesse will continue to enlighten our patients, wrongly or rightly, with or without our input. We can help by steering them towards more correct, more acceptable, more ratified and more evidence-based directions, or we can allow them to flounder about, with their misguided misconceptions and their spurious beliefs.

Our patients will become more demanding and will expect us to explain and expound more, while allowing them a chance to be better heard as well as to have a bigger say in the decision-making as to the individual management of his or her ailment or complaint. Do we have it in us to change and adapt accordingly? Or do we have to be forcefully challenged before we respond positively to these rising expectations?

In a recent meeting of the National Board of Medical Educators (NBME) in New York, the one emphasis showcased was that of focusing on the teaching of Empathy, "not the new technologies, drugs or discoveries." It appears that after decades of teaching and emphasizing medical knowledge and techniques, American medical schools are having a rethink as to their strategies of producing better physicians and doctors. For many of us who have been exposed to the US system of training and residency, it has been evident for some time now, that bedside teaching and patient communication has taken a back stage. In its place are the bewildering arrays and multitudes of new tests, probes and therapies, which are dished out to the hapless patient, in a near-blunderbuss fashion. Seemingly it would appear that doing everything possible and leaving no stone unturned has become the philosophical approach of the expensive American system of (perhaps, defensive) healthcare.

Now the NBME plans to add a doctor-patient communication module into the medical curriculum to meet the needs of increasing patient sensitivity as well as to perhaps stem the rising tide of malpractice suits. This follows an eye-opening public opinion poll by the Association of American Medical Colleges, which found that patients rate communication as the most important factor (85%!) in choosing a new doctor — ahead of board certification, number of years in medical practice or where the doctor attended medical school. Thus the teaching of empathy, effective communication skills and caring are to be re-introduced. Five basic communication skills are to be taught, i.e. establishing a relationship, gathering information, giving information, negotiating a treatment and closing a session.

Ironically, when the Ministry of Health decided upon such a scheme a year or two ago, many physicians (including myself) expressed much skepticism as to whether such a caring concept can be taught or imparted over a one- or two-day workshop. I still have reservations as to whether this is beneficial in such a truncated exercise. My contention is that medical schools have to inculcate these patient-doctor communication skills throughout their medical curricula. Nevertheless I stand corrected, and congratulate the ministry for its foresight in trying to reverse the tide of physicians’ or healthcare workers’ perceived lack of caring.

Has Medicine Lost Its Way?

Even before the announcement of the human genome story, medicine in this latter new era has been increasingly called to question by many thinkers, regarding its direction or misdirection. It is certainly true that modern medical and health care practices have undergone tremendous changes. Technological advances have made the practice of medicine more cold-blooded, more mercenary, and a whole lot less personal.

There are also probably many moments in a physician’s mind that evoke the question of the changing landscape of the pharmaceutical-medical-industrial complex. This gargantuan and tightly intermeshed web appears to be dictating the directions and terms of our progress in healthcare. There is growing medicalization of all manners of disease or of even newly defining disorders, previously considered as part of senescence, ageing, or which were simply quirks, traits or anomalies in the past. We have begun to label and re-label disorders, creating more ailments for which we can apply some sort of therapy – without real proof of our having done better or more benevolently.

We appear to have become trapped in the fanciful fashionable world of medical consumerism. Perhaps, it is time for us to have a re-assessment as to our values, our goals, and our purpose as a medical profession. Or do we continue to slide down the slippery slope of ethical amorality and so-called scientific pragmatism, which are constantly buffeted by the winds of technological change?

The sanctity of our Hippocratic oath and our raison d’Ítre i.e. patient-centredness must be preserved and given renewed courage of commitment. We cannot delude ourselves that medically scientific advances are the only true direction of where the profession should be pursuing. We have a moral right to question their benevolence, their greater goals—so as to protect our patients—from the incongruities and excesses of medical adventurism, driven by commercial pressures of the huge pharmaceutical and medical industrial complexes. Are we making more of ill health than is the acceptable case in reality? Even if this is not so, are we guilty of overstressing disorders and their accompanying therapies, rather than offering a more decent, happier and more holistic and tolerable life and living?

Finally, it is worth considering what medical historian Professor Porter (in The Greatest Benefit to Mankind – A Medical History of Humanity, 1998) has to say:

"We have invested disproportionately in a form of medicine (‘Band-Aid’ salvage) whose benefits often come late, which buy a little time, and which are easily nullified by external, countervailing factors. Curative, interventionist medicine has played a modest part in shaping wider morbidity and mortality patterns within the community, but in terms of its professed aims – the greatest health of the greatest number – the Olympian verdict must be that much medicine had been off target."

"… Medicine has become the prisoner of its success. Having conquered many grave diseases and provided relief from suffering, its mandate has become muddled. What are its aims? Where is it to stop? Is its prime duty to keep people alive as long as possible, willy-nilly, whatever the circumstances? Is its charge to make people lead healthy lives? Or is it but a service industry, on tap to fulfil whatever fantasies its clients may frame for their bodies, be they cosmetic surgery and designer bodies or the longing of post-menopausal women to have babies? … It may be that medicine has to learn that lesson all over again."

"Doctors and ‘consumers’ are becoming locked within a fantasy that everyone has something wrong with them, everyone and everything can be cured. Medical consumerism – like all sorts of consumerism, but more menacingly – is designed to be unsatisfying, The law of diminishing returns necessarily applies. Extending life becomes feasible, but it may be a life exposed to degrading neglect as resources grow over-stretched and politics turn mean. What an ignominious destiny if the future of medicine turns into bestowing meagre increments of unenjoyed life! … Medicine has led to inflated expectations, which the public eagerly swallowed. Yet as those expectations become unlimited, they are unfulfillable: medicine will have to redefine its limits even as it extends its capacities."

July 2000

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