Abiding
Clinical Truths
Abiding truths there are in medicine and though few in
number they may yet bring comfort to our embattled colleagues. We are
in a time of change in medicine more profound perhaps than in any
other part of life. Nothing like this has been seen before. Doctors
are reasonably and increasingly uneasy and unhappy with current
system dysfunctions but beyond that there is an unspoken fear of some
looming threat that lurks unseen or if dimly perceived evokes
widespread denial. Diagnoses there are aplenty but none consoles and
leadership is absent. Prognoses, as ever uncertain and frequently
doom-ladened, lead away from what we desire. This is natural. We are
in the early stages of a millennial change in how we contribute to
human well being yet armed with our abiding truths we shall
comprehend and succeed in our honourable mission.
To
map the future it can help to review the past. Our remote
predecessors started from nothing and constructed a clinical system
based on appeals to intuitive overarching principles and at times
supernatural authority. It was however imbued with unspoken truths
which still abide. With a significant incidence of self limiting
illness, a modicum of luck and a pervasive fatalism, it sufficed for
thousands of years. Progress was made with the growing adoption of
empirical observation, understanding the basics of biology, and the
application of the scientific method. Mainstream medical progress
was to follow this path while alternative practitioners continued to
appeal to principle, system and invisible influence. The two
traditions survive today and both have a role.
The
tenets of scientific medicine came to be implanted in the minds of
high achieving individuals trained as bioscientists and sent into
independent practice to make the best judgements they could. This
model, formalised by Abraham Flexner in his report of 1910, though
imperfect, has served as well as any that might have been proposed.
Today’s practitioners were selected, educated and trained in this
model, rejoicing in its strengths while ignoring its weaknesses. We
were to do our best armed with what we had been told was established
knowledge from the past, rationale applied to the clinical situation
in the light of our scientific knowledge and a growing personal
experience, tempered always by a deference to the patient’s
preferences and a submission to the practical constraints of the
system within which we practiced. Thus was the professional doctor,
educated, independent, autonomous in selection of approach and in
command of resources which for long enough were scarce, largely
ineffectual yet mercifully inexpensive. These features, common to us
all this last century or so do not however constitute abiding truths.
They were the best fit for the times. It was a shaky achievement;
reliable knowledge was scarce, the application of rationale yields
many false conclusions and personal experience is not only patchy and
fragmented but in the absence of searchable records is likely to be
incompletely and selectively recalled.
The
20th century brought great advances which accelerated after 1945.
Clinical practice costs grew as more effective responses to the
patient’s distress became available. More complex investigations,
biochemistry, pathology imaging and endoscopy fuelled more effective
surgery, radiation and chemotherapy driving up costs. Patients
responses to mishap became more demanding and their settlements more
expensive. Funders started to take notice and tried to act. Their
ability to effect change was stymied by the lack of any knowledge or
agreement within the profession of how specific illnesses might be
most effectively (or even most economically) treated. Healthcare
organisations busied themselves with reorganisations and tinkered
with financial management and infrastructure.
Change
was coming. In 1983 the United States federal government introduced
Diagnosis Related Groups to set Medicare payments for inpatient
stays. This stepped away from funders unquestioningly paying for
whatever the doctor ordered and offered incentives to hospitals to
question the details of the clinical process. In 1990 the world
changed in UK medicine with the transfer to the NHS of responsibility
for claims of negligence by hospital doctors. Globally this would
seem a suitable zero in the chronology of change. Organisations now
had responsibility for increasingly expensive aspects of the outcomes
of clinical practice and surely could not long accept that
responsibility without commensurate authority. The bomb was ticking.
The following year in the UK we had not only, responding to
burgeoning consumerism, the Prime Minister’s “Citizen’s
Charter”, which led on quickly to waiting time guarantees, but also
the “New Deal” for junior doctors which though long delayed in
the implementation offered the prospect of safer and more humane
working hours over the strident protestations of much of the
profession both senior and junior. The status quo has enduring
appeal. Management was on the move asking unprecedented questions
about the basics of clinical decision making, entering new and
unfamiliar territory with new ambitions and expectations but still
lacking the crucial ability to question the utility of individual
clinical decisions since there were largely no agreed answers to any
questions on the details of clinical practice. That year however a
young Canadian doctor, Gordon Guyatt, delivered the keys to the
kingdom of medicine with a short paper promoting the notion of
“Evidence Based Medicine”. He has not been forgiven. To this day
many column inches are given over to those hurt, confused and in
denial of the changes that EBM has brought. His work (and that of his
mentor David Sackett) symbolised by that initial paper was akin to
the assassination of the Archduke at Sarajevo in 1914. It was not the
cause of what followed but it was the trigger. The next 25 years saw
tumultuous change. Yet this was only a prelude.
But
what of abiding truths? Humankind has always experienced symptoms
though the concept took time to be clear. Everyone has distressing
experiences which suggest disordered function of the body or the
mind. These are common almost universal and the majority are probably
unknown to medicine. With the advent of professional therapists
symptomatic individuals could seek help beyond their own resources or
those of their immediate circle. Such a person became a patient.
Patients come to the clinical encounter with two objectives; to gain
relief from current distress and to receive reassuring advice on
improving future prospects. To this end they have three tasks; to
recount their experiences, to select from suggestions made by the
clinician and to instruct the implementation of chosen interventions.
The clinician can usefully also be conceived to have three tasks; to
assess the situation, to make recommendations for action and to enact
the patient’s instructions. That structure has been there from the
flickering lamp of the cave shelter of our remote ancestors and is
still there in the brightly lit technology rich clinic of today. It
will survive for as long as mankind does and well beyond our survival
as traditional medical practitioners. To supplement this structural
arrangement we might note the patient’s objectives as to the manner
of the encounter; to achieve relief and to be afforded assurance in
an accessible, safe, effective, convenient, comforting, comfortable,
confidential and economical manner. And these are the abiding
truths of medicine.
But,
in our distress, we insist that we are doing all that so what is the
problem? Simply put, for our patients the current methods of delivery
of care are unnecessary and overly expensive and for the
traditionally educated and trained doctor they are increasingly
trying and frustrating. The removal of clinical autonomy anticipated
and realised is as burdensome to us as is its progression and
inevitability. Newer types of clinician, drawn from more varied
backgrounds, already supported by the products of EBM, and with
clinically responsive information technology and ultimately
artificial intelligence to come, can and increasingly will provide
clinical care of a high standard. The current “Flexner” doctor in
much smaller numbers will be more usefully and satisfyingly deployed
for the greater part in the exploration and development of new
diagnostic and therapeutic possibilities. Every patient to some
degree will participate in clinical R&D. With robust electronic
health records, accurately captured and summarised, the accumulation
of the collective experience of healthcare organisations will become
increasingly available to support clinicians. Behind the clinical
endeavour sophisticated IT will extract and present usable
information from the free text repository of both clinical practice
and research and use it to construct more complex algorithms to
guide clinical advice. Clinical care will move progressively from the
varyingly effective, autonomous process of the past and present to
structured evidence based care delivered by a much wider range of
clinicians with varying skills, progressing to automated responses
and ultimately fully fledged artificial intelligence.
Yet
still we hear the cry, “Patients want more than this.” That is a
view which is understandable yet in part misguided. It is true that
individuals today spend significantly on alternative medicine which
by any reasonable assessment is ineffective. We are told it brings a
level of comfort absent in orthodox medicine but such claims are
nebulous and unquantified. To unlock this quandary we need to step
back for a moment and reflect that modern orthodox medicine has large
areas where it also is ineffective. Bluntly put, medicine has made
signal progress in areas where the patient’s illness can
confidently be attributed to demonstrable pathology, to
physico-chemical disorder, to disease. But much illness is not of
this sort and orthodox medicine is largely powerless to help beyond a
kind and attentive and at times perfunctory response. Alternative
medicine shrewdly and yet intuitively recognises our weaknesses and
the value of charisma and theatre in evoking gratitude and a sense of
wellbeing, while silently accepting its shared limitations in
effecting significant improvement. The best traditional doctors
always had a double approach but with the advent of effective
therapies we correctly emphasise these aspects and proceed. It is
also harder to have an unambiguously healing persona when the core
therapies bring short term distress often well before long term
benefit. Surgeons before 1847 and the advent of anaesthesia were
appreciated by society yet socially were held somewhat apart in
recognition of imagined possible future relationships. Do modern
oncologists evoke a similar ambivalent attitude? Psychiatrists even
cause distress in their efforts to bring relief. Alternative medicine
practitioners have no such barriers to universal approbation. As they
have no upside apparent to us they have no downside apparent to their
patients.
However
that may be, our abiding truths will survive and will be ever present
despite radical transformations in the methods of clinical practice.
We are moving to a new model where our traditional scientific
doctoring skills will be more focussed and in the hands of fewer
individuals working with a wider range of clinicians all of whom
will however continue to exhibit the core clinical skill of
consistently and confidently making correct predictions. The patients
will have more success in pursuit of their objectives and whether by
the resolution of disease or a better understanding and response to
existential dread, medicine will have moved on past the current
uneasy compromises.
