A couple of years ago I had an ear infection. I had never had an ear infection before and can honestly say it was the most painful thing I have ever had (I was going to say worse than childbirth but seeing as I had a planned caesarean under spinal anaesthetic which was completely painless, I wasn’t sure the comparison stood up). The ear infection started at work one Tuesday morning when I was a trainee solicitor. At lunchtime I went to a walk-in clinic where they gave me antibiotics. By that evening, however, the side of my head had gone numb, was throbbing and I was convinced something serious was wrong so went to A&E. More antibiotics and heavy duty painkillers. 5 days later, 3 days off work, 2 GP visits (more tablets) and it didn’t seem to be getting any better. It was Sunday by this time and I was desperate.
Susen had an ‘uncle’ (a family friend and colleague rather than real uncle) in Birmingham who was an ENT surgeon (now retired) and he sought his advice over what to do. His uncle kindly offered to see me that afternoon at his Birmingham house where he had a fully equipped clinic attached to the house where he used to see his private patients. This shows how desperate I was as normally my middle class conditioning to not bother anyone, or be a burden would have won over. Instead I gratefully agreed and we drove up to Birmingham.
As we sat in the lounge and chatted initially it was mainly social catching up, but I was also aware that Susen’s uncle was carefully watching me, looking at whether I could move my face and talk easily. Examining me in his clinic, what struck me was his focus and craftsmanship in his work, obviously honed through years of experience. It was his profession and an art. He tactfully waited until Susen had gone to get something from the car to ask if I was pregnant (concerned about all the medications I was taking by that point) – just in case I was but Susen didn’t know (I wasn’t). His diagnosis differed from the GP’s but turned out to be spot on. I followed his advice and thankfully the ear infection cleared up over the next few days.
After the examination, we talked over tea and
mishti (Bengali sweets). He reminisced about meeting Susen’s father when he first came to the UK from his Calcutta medical college, about how pleased he was to find a fellow Bengali doctor and eating Susen’s mother’s lamb chops (not chops as we know them, but a spicy fried snack made with minced lamb or mutton). He said something that struck me at the time, and has stayed with me. Talking about his work as a surgeon he said he usually went in on a Saturday as it was his duty to see how his patients he had operated on the day before were getting on. It was the use of the word ‘
duty’ that was interesting. For him, there was nothing about having to because of a rota, or concern about possible negligence if he didn’t. Instead it was his duty to his patients to make sure they were OK and recovering.
I know quite a few doctors (and indeed had a long relationship with a doctor (of Indian origin) during my 20s) and it has long been the profession of choice for first and second generation immigrants to the UK, as a sure route to stability, money and status. I have heard quite a few stories of counting down the minutes to 5pm then switching off their bleep on the dot of 5pm so that anything that happened after that was the on-call’s problem, not theirs. Or now, as consultants, of being very well-paid for what they do – too much to consider leaving – but having very little interest in the practise of medicine, or duty to patients. I am sure they are very good at what they do, but it’s just a job where you go in and do what you have to do, then leave. Or of female GPs who keep on working their part-time hours purely because they earn too much from it to give it up – it pays for their children’s private school fees.
I absolutely understand that a lot of the behaviour of junior doctors was due to long hours on call, stress and overwork. I am also sure there are many doctors out there who do have a sense of vocation and duty. For Susen’s father, medicine – or surgery in his case – was his life. It occupied both his working and leisure time, as he attended conferences, kept up with medical journals and set up groups and events in the UK for graduates of his Calcutta medical college.
But something has changed. At the moment, many consultant’s contracts say they cannot be required to work at weekends – something Sir Bruce Keogh, medical director of the NHS is trying to change. The absence of senior doctors in hospitals at weekends has been linked to higher death rates and complications at weekends than during the week, with an estimated 4,400 people dying every year as a result
[1]. For similar professions in the private sector – such as law or accountancy - it would be rare to never have to work at weekends when required on occasion – although many doctors will use time at the weekends to practise privately.
Then there is the advent of evidence-based medicine, NICE
[2] guidelines, protocols and care pathways which have all sought to change medicine into a science. No longer relying on the doctor’s own clinical judgment from years of experience, with an individualised therapeutic encounter between physician and patient, evidence-based medicine seeks to standardise the diagnosis and treatment with evidence of efficacy demonstrated through the latest randomised controlled trial or meta-analysis. The doctor’s own clinical judgment becomes constrained by guidelines and fear of legal proceedings for negligence if the standardised treatment plan is not followed. It’s easy to mourn the loss of the art of medicine in this era of trials and evidence-based medicine, but it’s important to remember the huge benefits and gains as well. We might still be using ineffective or even downright dangerous treatments such as mercury or blood letting if medical science had not intervened. Or, even more recently, still think that stomach ulcers were primarily caused by stress or lifestyle rather than a bacteria
[3] - not to mention the development of modern anaesthetics. It could be argued that doctors today have a greater duty towards their patients than in the past – when, perhaps, mistakes went unchallenged or unnoticed.
Of course, development and testing of new treatments costs money with the potential to make pharmaceutical companies huge profits if successful. So, medicine is not now an art or a science, but a business. Nowhere is this more obvious than in a mainly private healthcare market such as the US – where healthcare expenditure is currently around 18% of GDP – and growing – compared to around 9.5% in the UK. Nirmal Joshi, writing in The Guardian this week
[4] says, ‘Being a doctor was once a job with a great purpose. Now it’s just a business’. Joshi, an Indian-trained doctor has been working in the US for the past 3 decades. He writes of his frustration at being pressured to see more and more patients in less time where they have become ‘more like business transactions rather than what they should be: rich and intensely human interactions potentially resulting in tremendous fulfilment for both parties’. Joshi wants a ‘spirited discussion’ on ‘real healthcare reform’ and says he is looking for ‘the simply joy that large compensation packages will never bring: the joy that my father felt in treating the poor farmers and others in the small Indian town of Nainital’.
It is perhaps the loss of this human interaction and individual-focus in the therapeutic encounter between doctor and patient that has made alternative medicine so popular in the last few years. An acupuncturist or homeopath can undoubtedly give the kind of time and attention in a consultation lasting 45 minutes or an hour that your average GP or hospital doctor cannot. And it is this human interaction that can be so important in a healing process – and probably the mechanism by which many alternative treatments work (via the powerful placebo effect) than through the particular efficacy of acupuncture needles or homeopathic pills.
Many professionals, including doctors, want to feel that they are practising for a more noble purpose such as helping others in need or improving society, rather than seeing their profession as ‘just a business’. Doctors working in the NHS in the UK have the luxury of not directly having to think about the costs of treatment and so can claim more noble motivations than being in it purely for the money or sullied by such notions of financial transactions. This belies the fact, however, that doctors are in fact richly rewarded in the UK for their efforts, being paid for not directly from the patient but indirectly through the tax system, funded ultimately by you and me.
By downgrading business ideas as Joshi does by saying medicine now is ‘just a business’ it also ignores the contribution that innovative business models and ideas can make to improving healthcare. A rich and intense human interaction bringing ‘tremendous fulfilment’ to both parties is no good if the treatment is ultimately ineffective (except through a placebo effect) or if the cost of the encounter is prohibitive to the majority of the population.
It was precisely by taking one of the oldest business model innovations – the assembly or production line model invented by Henry Ford more than 100 years ago – that the Narayana Hrudayalaya Hospital in Bangalore is revolutionising heart surgery in India
[5]. Sometimes referred to as the ‘Henry Ford of heart surgery’ Dr Devi Shetty, who founded Narayana Health in 2000 has brought economies of scale and a factory-like style to the provision of cardiac surgery in India where surgeons carry out around 12% of all India’s cardiac procedures
[6]. The average cost is around $1600 for coronary bypass surgery, compared to over $100,000 in the US
[7] and Dr Shetty wants to reduce this price to $800 in a decade. This has not been at the expense of quality, as one might suspect. The Narayana Hrudayalaya reports a 1.4% mortality within 30 days of coronary bypass surgery – compared to an average of 1.9% in the US, despite the fact that the Indian patients are often higher-risk
[8]. This model has shown it is possible to bring high quality health care at a low cost to a large number of people.
Other innovations in healthcare, borrowed from other sectors or businesses include the use of checklists
[9]. The idea of checklists was taken from the aviation industry where their use in standardising procedures for pilots contributed to a huge improvement in aircraft safety. The same idea is now being used in anaesthesia and surgery, where a similar improvement in patient safety is also being seen. According to Brian Jarman, of Imperial College London, the introduction of checklists in 3 hospitals in 2007 was associated with 255 fewer deaths than the previous year. Checklists, together with better team working and flattened hierarchies within teams are said to have led to better patient safety and fewer deaths.
So, while perhaps mourning the decline of medicine as an art, with a unique relationship between doctor and patient, let’s not forget the value and benefit of medicine being developed as a science and a business. The best would probably be to combine all three.
[1] As reported in The Telegraph 15/12/2013
[2] National Institute for Health and Care Excellence - UK
[4] The Guardian, 22 Feb 2014
[5] Featured recently on ‘IndianHospital’ broadcast by Al Jazeera TV
[6] From the INSEAD blog – Karan Girotra 5 Feb 2012
[7] Figures from Bloomberg.com 28 July 2013
[8] From the INSEAD blog – see note 6
[9] See ‘The Checklist Manifesto’ – the much acclaimed book by surgeon Atul Gawande
