The practice of medicine has changed dramatically during my professional lifetime. The difference is due in part to developments in our understanding of the scientific basis of the subject, but this factor has not been as remarkable or as affecting as the change in attitude to disease and to treatment.
When I was a student, most illness was thought to be due to “an act of God.” We recognised a few “acts of man”—the industrial diseases for example—but it was thought that the majority of diseases struck like lightning, at random. Another difference in our attribution of cause was our attitude to psychosomatic disease. Only a handful of diseases were thought to be caused or modified by the patient’s mind. A third difference was that “positive health” was regarded as the concern of a small number of doctors who specialised in what was then known as Public Health. They were mainly concerned with sanitation and the working conditions in factories. Few doctors felt that they had a role to play in keeping the nation healthy; neither did the public. Most of us felt that our role was analogous, albeit at a higher level, to that of a garage mechanic. We were concerned with repair rather than with design or misuse.
The smaller number of tests then available were more often used to establish the diagnosis than to exclude disease. The reverse is now true.
We used to offer treatment in a different way. Whereas the best doctors have always explained what they were doing, given reasons for their decisions, and encouraged the patients to take the medicines, the average doctor would hand out therapy much in the way a postman delivers letters. That is to say, he is required to deliver them, but not to ensure that you read them. The view was that the patient consulted a doctor because he wanted to be rid of disease, and that the doctor’s job was to give him something which would achieve that end. Once the patient had been given the prescription or the advice on a take it or leave it basis, it was assumed that he would take it, and that the doctor’s task ended there. He would of course try again if the patient failed to respond to treatment. The patients’ expectations were low and they did not seem to find the de haut en bas ethos offensive. I am glad to say that they now do—undue humility is hard to take—and this change in demand has been a major stimulus to better performance.
The information explosion can be coped with relatively easily if you read the journals, listen to your colleagues and keep an open mind—not too open a mind because that may allow the best things to fall out, and they may be replaced with misconceptions. You must find a filter of the correct mesh which governs the flow into and out of your mind. If you change your routine with every innovation, you will not be able to assess your results properly. Good clinical practice needs a relatively stable data base.
The change in attitude to psychosomatic disease has inverted the previous situation and it is now felt that there are few diseases which are not either wholly or partially influenced by the mind, both in their genesis and in their cure.
At the turn of the century the expectation of life of a neonate was 50 years. It has now increased to 73 years. It is argued that this improvement is due to social conditions rather than to medicine, and I am quite certain that this view is wrong. However, regardless of the cause, the fact is that people are living longer and they have been relieved of the burden of infectious diseases and a host of other illnesses which formerly killed many people in middle life. As serious disease has become less common, so patients have begun to take their lesser symptoms more seriously. This means that doctors are consulted earlier, and on more “trivial” matters. Triviality lies in the eye of the beholder, but the trend has necessitated a change in the doctor’s view as to what is trivial and what is not; a good working rule is that a patient is unlikely to come to see a doctor unless there is something which is troubling him, but of course the presenting symptom may not be the real reason for the visit. There can be few people who enjoy the inconvenience of coming to see a doctor. The spirit of the times has necessitated a great change in the way in which we view our role. So much for change.
Many of the attributes of a proper doctor remain unchanged. The first consideration was, and remains, common-sense. Like height, it is largely genetically determined. As it is difficult to define, and even more difficult to measure, it is not possible to tell whether it can be changed or not. I fear not. The next most important attribute of the effective clinician is his professionalism. This means taking a personal pride in getting everything right every time. One of the most harmful sayings in the language is “Everyone makes mistakes.” They do, but what distinguishes the craftsman from the botcher is that he takes care to make as few mistakes as possible. This difference in attitude makes a world of difference to the incidence of mistakes. As Shakespeare says, “lay not that flattering unction to thy soul.” You must act on the assumption that by taking care you can avoid making any mistakes.
The open-mindedness which characterises your attitude to information is absent from your attitude to your professional principles. You practise within a rigid self-imposed framework. Although you are in theory prepared to change a principle, you rarely do. You may change one as an act of will if after prolonged consideration it no longer seems to be correct, but you do not allow your principles to slide for an instant. If for example you have a rule that you never subject a patient to a test that you would not have yourself in like circumstances, then you stick to it all times.
The last of the many characteristics of the complete clinician which I mentioned in the first chapter, and the one with which I would like to end the book, is the concept of your role. You have your job simply and solely to “service” the patients. That is what you are trained and paid to do. You are “In service.” This does not imply that you are servile, but it means that whilst you have an interesting, rewarding job and are paid reasonably well, your main function is to satisfy the needs of the patients. It might be worth reading the passage below the book’s dedication again.