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Saturday, 25.03.2017

David Healy: Shipwreck of the Singular

Samuel Gershon’s comment

 

David Healy has presented a portrait of concerns about the science and practice of medicine. He has given us a series of perspectives which clearly raise appropriate demands for discussion and hopefully a plan for action. Barry Blackwell in his elegant presentation has focused on some of these issues to elaborate them from his unique perspective. Some of the others who commented on Healy’s essay have given their unique contributions to these mounting cracks and fissures in our medical edifice.

           I wish to add my pent up unhappiness to some of the issues raised by my colleagues. I have a long list as I am the oldest of this group and the curmudgeonliest. I have spent all my professional life in universities from lecturer to Vice Chancellor for Research for the Health Sciences. So, I will start by calling on my long term memory and perspective to profess tonal relationships in the field of medicine broadly.

            In the 1950’s, I was a junior faculty member in the Department of Pharmacology at the University of Melbourne and we were going to have our first child. I wanted to obtain the help of the best obstetrician in Melbourne and found that that would be the Professor of Obstetrics. I arranged to see him and asked for his help in overseeing the pregnancy and the actual delivery of the baby. He agreed to both. All went very well, and we reached the delivery time and my wife and I proceeded to the university maternity hospital and were met there by our obstetrician. I had arranged with the doctors support to be present during delivery. However, when I restated my intent, to the head nurse, she refused my request and the request of the doctor. So, the doctor said he would arrange for us to go to the other university hospital and things would proceed satisfactorily there. We all transferred to the other hospital and now all went perfectly well for all of us. I did not get any bill or other financial notification from the doctor and called his secretary to ask about this. She told me that the Professor wanted to inform me that this was his practice in such cases to offer professional courtesy. To top off this story, my son’s birth took place on New Year’s Eve.

This example of professional relations was repeated on all other occasions while I was in Melbourne. But on a broader scale, while I was at this University, my interaction with other faculty at the professional level was cordial and helpful. This was very important for me as I was trying to venture forth in research in which I was completely ignorant. I received every sort of help from junior and senior faculty and the Chairman of Physiology matched me up with a mentor.

           I apologize for this long introduction on professional relationships between colleagues, because I find this free, supportive and generous relationship is rare now, if present at all. I will not expound on this further, suffice it to say that in my later experiences, mainly in the US, were in adjudicating problems between faculty rather than enjoying the aforementioned supportive professional relationships. This attitudinal shift, I believe, has now also come to affect the doctor patient relationship. I would conclude that this high level of ethical behavior has become obsolete.

           

Doctor-Patient Relationships

    

This can be viewed from several aspects. For the doctor functioning in a hospital setting, the Hospital management has now assumed the primary, if not absolute role in setting policy and rules. The hospital, [including university] hospitals, have developed into corporate entities like other businesses providing services or products other than healthcare.  One single dramatic step was to centralize all appointments for doctors in that institution. For example, ascentral scheduling books all appointment for each PROVIDOR, the language for all things changes. They could schedule appointments for 12, 15 or say 20 minutes per patient, and the “provider” would have to fulfill this order, however long it may take, OR he could abide by the schedule, whatever time that patient may need. Now, automatically, the relationship between these two parties has changed. How does the provision of an empathetic relationship survive? How can patients be educated about their illness, its effect on their lives and the role and function of treatment?

         These practices are, more or less, carried over to private practice settings as well.

 

Medical Education,

         I wish to offer an historical perspective here, as well, as a main function of INHH is to examine the history of events that led up to where we are.

            My experience as a medical student began about 1944-5. I attended the University of Sydney, which was considered to be a good medical school. The 4th year was the beginning of the clinical rotations. We were taught Medicine by the new Professor of Medicine, recruited from Scotland. He was a small gentleman and had a Scottish accent and he had recently written a large 2-volume textbook, entitled The Physical Examination of the Patient. He went through his clinical demonstration of the examination of patients according to his textbook. He also demanded the collection of historical medical information with the same exactitude. His point to the students was that you take a full and detailed history of the patient and then complete a full and thorough physical examination. Then the result should be that you could provide at least a tentative or differential diagnosis. So far you have not had access to any laboratory tests. His requirement was that if you had not reached these aims, you STOP and start again. This example of medical education in the last century is certainly NOT practiced today.  In fact, current corporate models of medical practice have essentially outlawed this form of medical care.

        My contention is that the history that I have tried to present is part of what has and is destroying the science and practice of medicine. It has also contributed to all the many other ills that my colleagues have presented

 

Big Pharma

       My colleagues have discussed many times the contribution that this villain has made to medicine, equally the education, the science and practice of medicine. But we should be more comprehensive in our views, it is not just BIG BAD PHARMA; it is the MEDICAL INDUSTRIAL COMPLEX. The part that is not expressed clearly is that WE, the physicians, experts and scientists in this field have played a major role as enablers in this outcome. Some of the individual examples of this have come before the public, but many members of the related disciplines have been involved at many levels of this COMPLEX and continue to do so to the present.

       

Conclusion

            I agree with my colleagues in regard to their issues and concerns that have diminished our disciplines, but as I have tried to show it has been a slow and progressive and incremental disease. It will take the same hard steps that I have mentioned to try to right this Titanic. My colleagues have mentioned some of the key figures who first corrected the deficits they found and we are now again at a stage that needs leaders who can see the damage and summon forces to right it.

 

 

Samuel Gershon

April 28, 2016