Doctors, patients, manners and morals

Doctors' responsibilities
Doctors in general, like lawyers and politicians, have always been mistrusted by laymen but individual practitioners may be lauded beyond their desserts

Most doctors have been moved by a sense of vocation to try to help their less fortunate fellow- creatures. They have undergone a long period of training which is intellectually satisfying and prepares them as well to achieve their aims. Sadly, some are motivated by mercenary ambitions. These provide a problem for the future of the medical profession. Those who have neglected their duty to the society in which they live should be reminded of their responsibilities. This is best done by open discussion among their peers, not by rigid rules laid down by an outside authority.‘Doctors differ’is a common plaint among the lay - but they have always done so! This is healthy. They should consider carefully the views of‘lay members’of their community, informed in other disciplines. They may agree with some.removefullstop views and reject others as ill- advised but should never submit to regimentation. The debate on medical ethics continues and should continue among doctors and the public. Organ transplants and their donors, use of other animal tissues, the treatment of the infertile - test- tube babies, surrogate mothers and so on - genetic engineering, the survival of infants with congenital defects, the resuscitation of the moribund: these should continue to be discussed, with other problems, amongst doctors, amongst the public and between them both. They are matters of life and death.

Mammon prevails
Technological advances are expensive. We are now told that‘market forces’should reign supreme. The importance of ethics and altruism are ignored by our political masters. They cannot understand any other religious belief than the worship of the Golden Calf. This sets back Christians and Jews for 2000 years but not, I trust, believers in other faiths and in civilised values. In the West there is not only a temptation, but a compulsion for doctors to earn their living by taking advantage of scientific progress by others and to compete with their former colleagues for financial gain. The labourer, dedicated to his work, is no longer worthy of his hire. There is another forgotten Biblical injunction: ‘Thou shalt not muzzle the ox that grindeth the corn. ’

In England, for centuries, physicians and surgeons - and others - competed for ‘customers’ among the sick. Only a little over a hundred years ago did they finally agree to share their knowledge with each other and to exchange it with information from different parts of the world. The art and science of medicine flourished, to the benefit of humanity. Now the forces of Mammon have set back progress, if - it is to be hoped - only temporarily.

Listening and talking to the patient
A few personal views by an octogenarian may be pertinent. A good doctor listens to his patients, tries to help them and to advise them, their relatives and friends. This may sometimes be difficult. Some accept his advice. Others are dismayed when he is honest enough to say that he cannot give an exact answer to their questions. Some, influenced by what they have read or heard, believe that he cannot be up- to- date. They demand a ‘second opinion’. This may delay urgent necessary investigation and treatment. It is sometimes difficult to grasp the deeper anxieties of a patient who may present symptoms which may seem obviously inexplicable. A simple explanation, however carefully phrased, may be misunderstood. It is not uncommon for the doctor to hear from relatives of the patient an entirely inaccurate version of what has been said.

Some years ago I saw an elderly man, emaciated and vomiting persistently. At laparotomy he proved to have an inoperable carcinoma obstructing the pylorus and infiltrating surrounding tissues, with metastases in the liver. All that I could do was a gastro- enterostomy to relieve the obstruction. This worked well and the patient was happier and more comfortable. Later I explained carefully to the patient’s son and daughter what I had done and what I could not do. I held out no great hopes for the future, but said that he should be in a less unhappy state until the inevitable outcome, which I hoped would be painless. They looked at me with starry eyes and said, ‘Thank you so much, doctor!We are so glad it is not cancer.'

Sensational reports are often published about how some patient has battled against disease and has ‘beaten the doctors’. He or she had survived far longer than the doctors had ‘given’ - hours, days, weeks, months or years. I have never known a doctor so silly as to pontificate thus. All that can be done is to outline possibilities. It is not within any doctor’s power to ‘give’ anything but the best help and advice that he can.

Blessed are the simple...
Curiously, doctors’ opinions are more likely to be misinterpreted by the well- read than by the uninformed patient. The latter are more often grateful for minor assistance than the former are for major services, which they take as their due. Simpler souls also tend to do better after any operative procedure than those handicapped by erroneous preconceptions.They are also less prone to the modern disease of litigation. Such is human nature!

Some prevailing principles and present practice
Hippocrates, the ‘Father of Medicine’, described the rules by which a doctor should govern himself. In some universities newly qualified doctors still take the Hippocratic Oath. Osler quotes one of Hippocrates’ precepts translated from Greek into Latin:‘Primum, non nocere’ remove the apostrophe in the middle - First, do no harm. Three hundred years after the time of Hippocrates, the Roman Terence, who was of Greek origin, wrote:‘Homo sum; humani nil a me alienum puto’.I am a man; I consider nothing human beyond my concern. This is the motto of The London Hospital. After St. Bartholomew’s, founded 800 years ago,it is one of the oldest and best- loved hospitals in England. Both are now threatened by the tide of what passes for thought among thepresent generation of politicians in Westminister. ‘Rationalisation’ and ‘cost- effectiveness’, measured by clerks and bureaucrats, are more important than the interests of the sick, represented by impotent doctors, nurses and patients.

Managers pullulate. In the National Health Service (NHS) they have increased two thousandfold. They are paid a bonus for the damage that they do. In hospitals, wards are closed, operation theatres have their hours of usefulness restricted, disillusioned doctors retire early, with a dearth -not surprisingly - of new blood to replace them, nurses are sacked and any efficient administrators are ‘made redundant’ in the Brave New World of the Market Economy.

The good will, which kept the NHS, with all its faults, alive and working has been destroyed.. I could go onad infinitum- I have made pages of notes, giving chapter and verse, but for now, enough!

Michael Reillyretired as a surgeon in the National Health Service in England. He resides at Magnolia Cottage, Harrowbeer Lane, Devon PL2. 4EA England

FROM THE WORLD WIDE WEB

Diagnostic tests to “rule- out” and truth
Ken Kipnis observes that physicians use laboratory studies to “rule out” a disease, a commonly used colloquialism. Physicians have not adequately educated the public (and perhaps ourselves) on the nature of laboratory studies.

There is NO laboratory test that is perfect - that always and forever finds true disease, and never falsely finds disease. Furthermore, laboratory tests use statistics to determine “normal” from “abnormal”, meaning that the 5% that is normal but at the extreme ranges will be called abnormal. This is part of the scientific basis of modern medicine. Thus, for any test, there are two grey zones - one is the imperfect nature of the technique, the other is use of statistics to distinguish disease.

This process also applies to radiographic data, though here the pattern is visual. Most of the statistics part were done in the radiology research, and in clinical use this is assumed. Just as no two fingerprints are alike, no two xrays are alike. X-rays by nature are hazy and indistinct, so the grey zone (no pun intended) can be large.

Because of such imperfection, physicians collect multiple kinds of data, based on the notion of finding more data that is “consistent with”, or “not consistent with” a specific diagnosis. Making a diagnosis is an incredibly complex process of pattern recognition: x, y, and z support an hypothesis of a disease, aa, and bb do not support it, but x, y and z have greater sensitivity and specificity, so the diagnosis is... Sometimes this is easy, sometimes very difficult.

I can imagine an astute attorney having a field day with this in court. But the truth is that scientific medicine is imprecise by design, even at its best. I suspect it’s difficult to remember this after you are the victim of such imprecision. Perhaps we don’t do enough to explain this beforethe data are collected.

Geoffrey E MooreMD, FACSM, Assistant Professor of Medicine, Preventive Cardiology, University of Pittsburg, PA, USA. Email:gem10@pop.pitt.edu