Posts tagged: medicine

Doctor’s Dilemma

Business Logo for Psychological and Neuropsychological IssuesIn 1909, George Bernard Shaw wrote a nonfiction companion piece to his play The Doctor’s Dilemma.  It should be kept in mind that the state of organized medicine had reached a nadir at this time in its history.  Europe and America abounded in headlines regarding infamous cures and infamous practice.  At the same time, public health initiatives were making real inroads into communicable diseases.  Medicine had reached a fork in the road of professional development.  Either it would degrade further into playing upon the fears and credulity of the populace, or it would lock step with the march of scientific inquiry and practice.  Mr. Shaw stepped into this discussion with several points he felt were necessary in order for medicine to follow the latter road and abandon the former.  Please consider these concepts in light of the era it was created, as well as the work that remains to be accomplished.

1)  Nothing is as dangerous as a poor doctor: not even a poor employer or a poor landlord.

2)  Of all the anti-social vested interests the worst is the vested interest in ill-health. Mr. Shaw was very much against the profit motive in medicine, and conceptualized it as the greatest impediment to achieving truly scientific medicine.  In an early phase of this treatise, he goes on to write…private medical practice is governed not by science, but by supply and demand; and however scientific a treatment may be, it cannot hold its place in the market if there is no demand for it; nor can the grossest quackery be kept off the market if there is a demand for it.

3)  Remember that an illness is a misdemeanor; and treat the doctor as an accessory unless he notifies every case to the Public Health Authority. Mr. Shaw was for greater transparency in medicine.  He believed that much of the confidentiality advanced by organized medicine assisted the doctor’s practice more than the patient’s health.

4)  Treat every death as a possible and under our present system a probable murder, by making it the subject of a reasonably conducted inquest; and execute the doctor, if necessary, as a doctor, by striking him off the register. This may be considered an extreme form of increasing accountability.

5)  Make up your mind how many doctors the community needs to keep it well.  Do not register more or less than this number; and let registration constitute the doctor a civil servant with a dignified living wage paid out of public funds. This harks back to Mr. Shaw’s belief that the greater the number of physicians practicing in a given area, the greater the pressure on the doctor to secure an income by any means available.

6)  Municipalize Harley Street. This is a famous street where very expensive medical specialists practice.

7)  Treat the private operator (doctor in private practice) exactly as you would treat a private executioner. A bit harsh.

8)  Treat persons who profess to be able to cure disease as you treat fortune tellers. Mr. Shaw perceived that most medical treatments are advanced because of habit, rather than usefulness.  It was the duty of the doctor to be above treatment based soley upon habit and tradition.  He wrote a bit earlier in this work…A respectable man will lie daily, in speech and in print, about the articles he is selling, because it is customary to do so.  He will flog his boy for telling a lie, because it is customary to do so…He will give the same boy a present on his birthday, and buy him a spade and bucket at the seaside, because it is customary to do so, being all the time neither particularly mendacious, nor particularly cruel, nor particularly generous, but simply incapable of ethical judgment or independent action.

9)  Keep the public carefully informed, by special statistics and announcements of individual cases, of all illnesses of doctors or in their families.

10) Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words “Remember that I too am mortal.” Mr. Shaw believed that much of the doctor’s difficulties in providing scientific treatment were the superstitions of the public.  He understood that frustrating the demands of the patient will quickly bankrupt the doctor.  Despite this understanding, he did not excuse the profession for gratifying the public need for a medical messiah.

11)  In legislation and social organization, proceed on the principle that invalids, meaning persons who cannot keep themselves alive by their own activities, cannot, beyond reason, expect to be kept alive by the activity of others. Mr. Shaw is alluding to the fact that society cannot afford to provide total care for all the needy, and that rationing care should be based upon the usefulness of the person.  A very dark proposition indeed.

12)  Do not try to live forever.  You will not succeed.

13)  Use your health, even to the point of wearing it out.  That is what it is for.  Spend all you have before you die; and do not outlive yourself. This may not be as roughly untrue as it sounds.  The evidence is piling up that antioxidants may actually reduce lifespan, since intermittent stress on the organism appears to increase length of life.  For example, exercise increases free radicals and stresses the organism, but it is indispensable to a healthy lifestyle.

14)  Take the utmost care to get well born and well brought up…Be particularly careful to have all this done at the expense of the nation, as otherwise it will not be done at all, the chances being about forty to one against your being able to pay for it directly yourself, even if you know how to set about it.

As a comedic writer, Mr. Shaw pushes concepts to absurdity in order to find humor in the mundane, such that a number of his statement shouldn’t be taken literally.  The core of his argument appears to be threefold.  First, that medicine was too reliant on ritual and tradition; all too often at the expense of the patient’s health.  Second, that organized medicine was too reliant on pushing more drugs and procedures, at the expense of the patient’s health and finances.  Third, that organized medicine was too isolated and insular, at the expense of the patient’s possible comprehension of their condition.  Regarding the present state of affairs, the gentle reader will have to judge for themselves whether the “was” in the last three sentences should be replaced with an “is.”  All in all, it is fortunate that the study of psychology was strictly an academic discipline at the time of Mr. Shaw’s excoriation of medicine.    It is likely that the Psychologist’s Dilemma would be equally unflattering.

Caretaker versus Doctor

Dr. Holzmacher's Business LogoIt is not unusual for me to deliver a particular admonishment to family and patients.  Sometimes people need a simple reminder; others need a figurative beating about the head and shoulders.  This warning is critical to the care of the people we love.  The essence of the advice is this-function as a caretaker rather than as a doctor when treating a loved one.

The definition of a human being invariably dwells on our fragile and temporary existence.  The most primitive of tribal cultures always includes a medicine man to counter this fragility.  Whether the setting is composed of desert nomads or slick urbanites, people consult specialists that smooth and extend their existence.  Once the specialist is consulted, patients arrive at their own decisions regarding treatment.  The specialist consulted may be termed an internist or shaman, yet both are healers that direct our behavior in pursuit of health.  The mission of all health specialists is to provide specific directions for others to follow.  Whether the treatment is eagle feathers or a new drug, the aim is to cure sickness and extend human life.  Neither the shaman or internist provide day-to-day physical or emotional care.

Most family members of ailing patients want to be as helpful as possible, and this is where the trouble begins.  Caregivers may cajole or force a loved one to comply with the directions of the health specialist, and find themselves ostracized by the one they are seeking to help.  There is no guarantee that the behaviors proscribed by the health specialist may cure or even be helpful.  Most long-term follow-up studies of actual patient compliance hover around five percent after one year.  Stated another way, ninety-five percent of people do not follow doctor’s orders.  Most people take more or less drugs than proscribed, and rarely comply with non-drug behaviors suggested by the physician.  The caretaker who is frustrated with their loved one’s lack of compliance are very likely to be poorly compliant themselves.  It’s good advice for the other guy.

All doctors can be replaced, though all caretakers are not replaceable.  Parents often comment that “I’m just a mother or father” when confronting disease in their children.  This often gives voice to the parent’s sense of helplessness and feelings of inferiority to the specialist.  The response I frequently employ is, “There are many doctors, but you are the only mother there will ever be.”  The emotional support of a mother, father, husband and wife are indispensable and irreplaceable.  Strangers may provide excellent physical care, but their actions do not have the emotional importance of close relations.  Occasionally I will turn the phrase around, stating to the parent, “I’m just the doctor, you’re the parent.”  It is an effort to reinforce the importance of the caregiver’s emotional support.

Even if you are a health care provider, do not fulfill that role with your loved ones.  There is no shortage of opinions regarding our health, but there is always a shortage of love and support when the chips are down.  Nagging a loved one into compliance with the doctor is more likely to result in bitter feelings than better health.  Such nagging may be taken as a need to control, rather than the need to see the patient regain their health.  As a parent, best friend or spouse, remember that the relations built over a lifetime cannot be replaced by a stranger-no matter how educated and skilled.  The non-specific factor in all forms of recovery is love and support.  Leave the specifics to the specialists.

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