Posts tagged: Psychology

Doctor’s Dilemma

In 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.

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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.

The Psychological Model

The medical versus psychological models of treatment are often discussed during psychological training.  The word “model” refers to the theoretical framework that each profession uses as their guiding principles.  Both medical and psychological models focus on signs and symptoms of illness.  The medical model relies heavily upon independent tests to prove or disprove if a patient is ill.  The psychological model also uses tests to prove or disprove whether a patient is ill.  It is at this point of agreement that the two models diverge.

The chasm that divides one model of treatment from the other is the subjective experience of the patient.  To most medical doctors, if the tests do not reveal a problem, then the patient is often perceived as hypochondriacal or even malingering.  To a psychologist, if the patient believes they have a problem, then they really do have a problem.  The subjective experience of the patient is considered most important, and objective measures less so.  For example, people often claim they are experiencing pain, even though objective tests did not discover damage to the organism.  The psychologist will note that there does not appear to be organic damage, yet the patient remains in obvious distress.  Psychologists are trained in the scientific method, which encourages constant skepticism.  A well trained psychologist should always keep in mind that no test is one hundred percent reliable, and there are always limitations regarding the extent of their validity.  In the example above, there may be actual organic damage to the patient causing their pain, but the current state of the art lacks a test to reliably identify the organic damage.

An obvious limitation to the psychological model is a patient that is unconscious, or their communication ability is compromised to the extent that they are unable to make their needs known to others.  Both medical and psychological models must rely upon objective tests to evaluate these type of patients.  There is no alternative.  When the patient regains consciousness, and is at least vaguely aware of their environment, then their subjective experience again becomes very important.  For example, patient’s who wake from a stroke to discover that they are unable to communicate often manifest great agitation.  Quite often, they are not aware of their own lack of expressive ability and believe others are making a game of pretending to not understand their verbiage.  The objective tests qualify and quantify the extent of damage to their brain, but the subjective experience is that loved ones and staff are playing an elaborate trick.
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The explosion of “alternative” medicine suggests that traditional medicine might be missing something.  Those patients that are attracted to alternative medicine do not completely eschew the traditional medicine model.  Consumers of alternative medicine still believe that substances outside our bodies have curative powers.  They tend to avoid products of traditional pharmaceutical companies in favor of medicinal preparations from other cultures or even antiquity.  The model of treatment is essentially the same, it is merely a change in the manufacturing and distribution of the medicines.  Clearly this group of consumers has health needs not adequately addressed by the traditional medical model, yet it remains to be seen if the “alternative” style of medical treatment is any more effective.

To paraphrase Andrew Still, anyone can find disease, but it takes a healer to find health.  The various qualities and techniques to become a “healer” are still less than scientific.  The failure of traditional and alternative medical models to address the subjective needs of the patient may be the missing link that completes the true healer.  Twenty years of clinical practice have convinced the author that people’s complaints are only loosely based upon reality, and this holds true for the author as well.  Humans have resisted efforts to equate mental and physical health with empirical evidence reminiscent of mechanical laws.  Empirical evidence should be the cornerstone of medical and psychological practice, yet the entire edifice is not created with these laws alone.  Understanding the subjective experience of the patient is a gift, both to the patient and their family.