Friday, February 14, 2014
The Highest Potential of Humanity in Medicine
Modern medicine is being dehumanised. Doctors, other healthcare professionals and patients alike feel it and are concerned. Something is missing. Something is being lost.
Confidence in the human abilities of the clinician is in decline. Even the clinicians’ own confidence in their own human abilities is degrading. So they increasingly delegate to the false certainty and security of science, technology and tests.
This is as much a societal issue as a professional one. It is vicious cycle as doctors conform to patients’ declining expectations of their human skills. Human, clinical acumen is devalued in practice and the motivation to learn those skills is lost. Acumen can no longer be trusted. Delegation increases.
Politicians, administrators and bean counters accelerate the process, cutting the clinical time to practice for cost cutting. Lawyers are turning practice into the second rate minimum standard of routines, algorithms and the hard evidence of defensive medicine. Every patient must be treated as standardised and average according to the science and technology of physical pathology and disease rather than complex, human individuals with particular psychosocial situations, desires and needs.
Medicine is being dehumanised from every angle. It is being dehumanised in reality.
This conflict of interests and expectations can only be reconciled in one way. The machines, technology and algorithms make all of the medical decisions and the human clinician is in their service. The human doctor or other healthcare professional becomes merely a human interface to the technology, firstly providing data entry services and then breaking and softening any bad news that the harsh tests and algorithms want delivering.
Or does the doctor have the right to ignore the protocols and technology just because the patient does not like what they say in terms of the diagnosis or the treatment?
That is the direction that basing medical practice on the lowest common denominator of Win/Lose, Lose/Win sales would take the medical profession and healthcare services. It is a situation in which everybody loses in the long term. Health suffers in every way. The once noble medical profession would be disgraced.
The endpoint is where society demands to know why it even needs doctors. Total dehumanisation is the inevitable conclusion of degenerating clinical skills and acumen. It is the consequence of medicine losing its human genius.
And this goes against everything that is believed of how modern medicine could and should be practiced. It is dangerously second rate medicine based on this discredited and disproven public trust in the certainty and safety of science and its technology in medicine. The evidence proves that they are neither certain nor safe.
False positives, false negatives and even complete errors are common and often endemic to the nature of the test. They have consequences and patients suffer and die as a result. Invasive and radiological investigations have significant short and long term risks. Surgery and anaesthesia obviously carry significant risks.
Over-medicalisation is bad for health at every level.
Pharmaceuticals are legally defined by their serious risks, side-effects and consequences. They are not primary defined by their therapeutic effectiveness. It is a secondary consideration. Many substances that are therapeutically effective according to the evidence are legally classified as food stuffs, additives or supplements because they are generally good for everybody and carry little in the way of risks or side-effects, including in overdose.
The list of therapeutically effective foods, additives and supplements is long and it starts with the water, dietary fibre, protein, calories, vitamins and minerals that are essential for the normal health of any life form to grow, develop and survive. Garlic, red wine, glucosamine and omega-3 fatty acids are amongst many examples of substances that have proven health benefits but that do not need a doctor’s prescription because they are relatively risk and side-effect free.
The license of the doctor is defined as having the education and training required to safely make individual, case by case, risk/benefit analyses for the use of investigations and therapies that are potentially harmful including the use of science and technology or anything that derives from them which requires a doctor’s professional signature or hand. Their legally defined role in society is the wise use and application of medical science and technology. They could and should be the masters of that science and technology, not its servant.
The dangers of over-medicalisation come into sharper focus with the modern understanding and evidence of the primary importance of the patient’s life style in maintaining their own health and preventing or managing diseases. The scientific and technological model of health fragments the whole patient. It fragments the complex human patient from their lives to leave what only the medical technology can do for the patients. Power and responsibility have been transferred. The patient has been disempowered. Hence, the monopolous use of science and technology in healthcare leads to medical dependency and the sick role.
Yet internationally, modern doctors are becoming dependent and reliant on science and technology. As they delegate decision making, they are losing confidence in their own human acumen and judgement despite clinical wisdom and the very definition of their license. The abilities and capabilities of the human clinician are being devalued, deprioritised and neglected.
It is happening in medical reality and practice because non-clinicians that only value the science and technology, including academics, lawyers and patients, and those intent on reducing the human cost of healthcare without understanding the costs and consequences of doing so, are eroding the culture that created the clinical arts. There is no time for the doctor to learn, practice or hone those arts. Patients are fobbed off with these tests, technology and over-medicalisation. A hollow veil of trust and satisfaction is created with this false paradigm that the science and technology of modern medicine are both safe and certain. Everybody suffers. Health suffers.
Of course, the bean counters shoot themselves in the foot by forcing doctors to order more expensive tests to create the illusion of good practice in lieu of finding out what is wrong or not wrong with the patients using their skills and acumen. Firstly, they need to see the patients a second time just for the results. They need to sort out the false positives and false negatives. Then the costs of the consequences and risks must be paid by the patient and the medical system.
I am put in mind of a TedX talk in which Dr Wen uses the case of one of her patients who came to hospital after doing a bit too much in the garden. His body ached including his chest so he was put into cardiac and respiratory protocols and was investigated invasively for everything. He nearly died, including pneumonia and major surgery for the aneurysm that was caused by the cardiac catheterisation.
Yes, clinical acumen is often just common sense but also having the confidence to use it rather than delegating to the science, technology and tests. However, it is becoming difficult in a medical world dominated by science and technology.
Dr Wen also gives herself as an example. She suffered asthma as a child and suffered not only pharmaceutical intervention but surgical intervention. An anomalous part of her lung was removed with no positive result. Then one day she was cured by a wise doctor who took the time to find out the cause of the problem. The irritation of her lungs was nocturnal as a result of sleeping with the window open. That window happened to be just above the extractor fan from the kitchen of a restaurant which was contaminating her supposedly clean, fresh air with smoke and fumes. The window was shut and she was cured.
These are becoming major issues in modern healthcare. A professional backlash is starting against the paradigm of science and technology in favour of a healthier balance with human clinical acumen. The science and technology are being put into their correct context. They are supposed to help medicine and health by assisting and supporting the clinical skills rather than replacing them.
Common sense, the wise and sparing use of science and technology on human risk benefit analyses and the importance of taking a full history of a patient’s life and thoroughly examining them are being replaced, especially in the US and any country that has followed their healthcare model and culture. These are just the basics of good, human medical and health care that are being forgotten and major literature and other media are now being produced to defend them particularly where they are most lacking.
Those are just the basics of human clinical abilities and skills that are being defended. Little is mentioned of the highest reaches of clinical acumen and the few that practiced to the fullness of their human potential.
Remember, human clinical acumen was once all that a doctor had. Their five senses and minds was all that they had to diagnose and treat. The possibility of reliance on the modern science and technology of medicine is very recent.
This created a generation of doctors who had learned to practice purely human medicine at the outset of their career. As science and technology came along, the best of them incorporated them into their clinical practice without detracting from the human side of medicine. The best of them also experienced, practiced and learned from the increasing importance of communication skills as their importance in healthcare became more apparent during their careers.
Far from all of the doctors of this generation achieved these highest standards of health and care. These are the stories of the exceptional few.
There was a spectrum. There were many very good to middling doctors but at the other end of that spectrum were a few dangerously arrogant and incompetent doctors who really did not care and got away with it at their patient’s expense. That was unacceptable to modern medicine and its reputation. Science and technology have been used to improve. They have provided a minimum standard of competence and care.
The problem is that the baby has been thrown out with the bathwater. The insensitive process of standardisation with science and technology has addressed the also-rans but at the same time denied medicine of its past geniuses.
This is the type of medicine of minimum acceptable standards that is being taught in medical schools and the academic teaching centres. It is all that many modern young doctors know or think possible. This is why they sit spellbound by another perspective of clinical practice that relied on human genius with science and technology playing second fiddle and a supportive role.
I was extremely fortunate to have had a series of past masters of the clinical arts as my mentors. I also learned from non-medical co-workers. Those arts were never restricted to just doctors. It was an environment where the human arts of medicine were valued and heeded as well as practiced.
The subtleties of the human arts of medicine often outperformed the science and technology in both their predictive accuracy and their specificity. Their human impressions and thought had greater predictive value than a number or hard radiographic image. These were truly geniuses of clinical intuition and inspiration. It could even be said that they actively inspired their patients to better health.
This is what is being lost, as students and junior doctors are only taught the mundane and routines of science, protocols and technology. The arts of medicine are in the realm of the old school of truly great human doctors and other clinical professionals whose wisdom is now retiring. Their experience is being lost.
To the mundane and closed mind of materialist science, which excludes anything beyond scientific comprehension, it seems infeasible that a human being can out-perceive a machine and out-think a computer algorithm. These are inexplicable and unimaginable feats. They make no sense, perhaps because we know so little scientifically about the human mind and brain as yet.
To doctors indoctrinated in this scientific culture, such feats and deeds needed to be seen to be believed possible. Rarely are they seen. Certainly they are no longer the norm and the expectation of every clinician. They have become feats of a gift of infeasible genius that cannot be reproduced. Or it is hoped that they shall be reproduced by experience and come with time as they did in the past. They should be a natural corollary of clinical experience as they were in the past when many doctors and other clinicians truly mastered their clinical arts. However the experience has changed.
The culture and environment has changed. The training has changed. The medical paradigms have changed. The societal context of beliefs, expectations and demands that medicine must conform to has changed.
The experience that allowed these genius clinical arts to develop over time is no longer what it was. The old norms and expectations are no longer normal. What was common once is now exceptional and incomprehensible genius never to be repeated or learned.
The environment that produced the highest levels of the clinical arts was like a evolved ecosystem that has been interfered with by those that did not understand its functioning or delicately interdependent nature. Nobody has really understood it beyond the vagaries of experience. Often the magical act of diagnostic intuition was put down to the words ‘I have seen it before’, that patients with a certain, perhaps unusual or atypical condition, all look, act, speak, feel or even smell the same. Something subtle but indescribable makes the diagnosis and that diagnosis is certain so long as the doctor does not try to think too much or rationalise what they know.
Perhaps all that can be said is that there is a mysterious part of the human mind that assimilates unconsciously the flood of sensory data to create a consistent picture that matches another picture from the past. It is certainly not the normal conscious mind and its linear, deductive thought processes. The subtlety and mass of the non-verbal information is simply beyond it. To the linear mind that can easily be expressed in rational words, this appears all but psychic.
The mystery deepens in that these ‘seen it before’ diagnoses can be made for conditions that have never been seen before. They are possible from getting a deep understanding and feeling for a disease from the very best textbooks when it fits into a perfected jigsaw of physiological, anatomical and pathological knowledge. The patient’s history and how it will be expressed is known. On examination, the hand becomes like a visual organ sensing and seeing how pressure makes the anatomy react as if scanning.
Clinical intuition is highly knowledge dependent. Knowledge is a part of the consistent jigsaws that are being created in this mysterious, non-linear part of the mind.
To the master of the clinical arts, the fragmented knowledge and understanding that was learned in medical school was never an end in itself. It was the first stage of a process in which it would all come together into a whole understanding of humanity. Fragmented knowledge is always floating in the background waiting to be put together into practice.
However, that scientific knowledge is only a part of the picture. It is possible to make a diagnosis before there is a single justifiable sign or symptom. The technological tests have not yet changed. It looks like pre-cognition, the ability to see the future from signs too subtle for the technology.
It has to be seen to be believed. Such feats of diagnosis make no sense to those who only believe in the science and technology rather than the potential of the human clinician. The science and technology cannot think like this. They cannot perceive like this. This is human potential that can only be practiced by the human mind.
To those that have only ever experienced linear, deductive rationality, this is magic. It is supernatural. It is beyond them. It is superhuman to their experience of human potential.
Actually, it is formally hyper-rational. Formal logic rejects their linear deductive processes as inferior to those that seek theories and diagnoses based on consistency with the entirety of the available evidence without exclusion. This is the highest standard of formal thought. It is seeing the whole picture.
It is also a higher state of the objectivity that academic science proclaims. This part of the mind appears able to extract the objective from the subjective and fill in the gaps. It sees between the words to know what is being expressed. It knows exactly which questions to ask to place all of the information in greater context.
Nothing can be hidden by words. Perhaps it is expressed by subconscious tone. Perhaps it is simply a matter of fully comprehending the non-verbal communication that is taking place.
Somewhere, deep within every patient, they know what is really wrong with them. Good nurses, even the best receptionists, see it. Often they feel it was a chill down their spine. They know it but they cannot express it. They do not have the words or concepts to express what they know. It is the intuitive doctor who has that knowledge. It is the inspired doctor who has the knowledge and power to do something about it.
Mothers know when something is seriously wrong with their child but know what is wrong. They do not have the words to explain it or concepts to express it. They can know before there is anything to find. In the textbooks this is described with undiagnostic vagueness as ‘how a child handles’. Attempts are made to rationalise and explain but the only real explanation is mother’s intuition if you know how to spot it. It is in her tone of voice and choice of words. There is a tranquil, uncertain, confused terror about her that she cannot put into words. She is concerned deeply but calm and compliant.
She expresses her intuition through her eyes. Meningitis can be diagnosed instantly on seeing a palpable silence in the mother’s eyes before the child even has a temperature, let alone neck stiffness or a rash.
Experience of doing this yourself is transformational especially when it saves a precious young life.
No, you cannot write that in a medical textbook or academic journal. It would offend those less able who rely on the linear, deductive mind. Their mindset demands the type of proof that can be measured by a machine rather than evidence. However, anybody who has worked at the sharp end of healthcare knows the importance of the silence. They know that silence foreshadows imminent death at the scene of a major accident. They seek the silence since that is where lives are saved.
Patients know the presence of death and they know that they do not have the energy to make a fuss. Their fear is contemplative and quiet as if their noisy ego dies first.
The silence affects on-lookers too. It can even affect those who are present but that do not see. Its presence affects all intuitively. Counter-intuitively, it does not cause panic. It clears minds. People intuitively quieten to efficiency and know what to do. Lay people know whom to call because it is the best that they can do under the circumstances.
And in these extremis circumstances, clinical egos vanish. Everybody knows what to do. Words are calm but deliberate. Experienced healthcare professionals function as a well oiled machine.
The core, ineffable mystery of the masters of the clinical arts is this silence.
This is the mystery of abstract, philosophical psychology of human potential that is beyond science. It is not considered in clinical psychology where the objective is only to get the drowning patient’s head above water. This human potential is usually only discussed in spiritual psychology and personal evolution.
To understand the past masters of the clinical arts and how those arts were learned and practiced requires that we delve into this abstract, philosophical psychology of human potential. True intuition and inspiration come from the silence of the superconscious, what Freud called the Super Ego.
Extending and clarifying Freud’s developmental model into later life, we can see the past masters of the clinical arts as having the wisdom of age. They conform perfectly to the idealistic traditional stereotype of the wise elder, matriarch or patriarch but empowered by knowledge.
For those that have never known an ideal matriarch or patriarch in this world of nuclear families and glorified youth, this person was a marvel. It was the person who could be trusted absolutely to always say and do their very best for you under all circumstances. They were secure enough in their position not to do what was popular but what would produce the best outcome and they were not frightened to tell you your part in a problem so that you could work on that and resolve it rather than simply blaming the other. They were unbiased and objective. At the same time, they were as caring as could be about their family or community. They were selflessly caring.
This seems entirely appropriate to medicine and the doctor-patient relationship. The miracle of traditional medical education and training was to accelerate personal development through the life stages to mature medical students and junior doctors to this advanced life stage by the time they were thirty.
Medical education and training was tough. It was done the brutal way without understanding or explaining why it was so and had to be so. The cultural purpose was to indoctrinate doctors to the deepest subconscious levels never think of personal interests but to always go beyond the call of duty for every patient regardless of hours or how the doctor felt.
This subconscious indoctrination was so profound that it overcame their natural physiology of stress and relaxation to allow them to function in otherwise untenable conditions. It even overcame their hormones. It overcame the doctor’s natural sexuality. They surrendered their gender to treat patients as a doctor should treat their patients rather than the average man or woman off the street. Psychologically, they did not have a sexual thought in their deeply professional life.
Certainly, all of the adolescent power games of sexuality had been erased from their conscious and subconscious mind. Adolescent egoism and competitiveness had been erased. They had been matured beyond such juvenile considerations. They would not talk or act for hollow popularity, only for health outcomes.
This calmed the chatter of the ego and allowed silence to be heard. It allowed intuition and inspiration to be heard.
To put this into perspective, the vocation of the monk was designed to achieve this in isolation and through blind faith rather than real world knowledge. After devoting their whole life to this path, they would perhaps reach this ecstatic state once or twice in meditation or prayer and perceive its peace and potential. They were mere observers of its peace and potential. The past masters of the clinical arts lived and used that selfless silence and potential as the source of genius in their everyday work.
This was also the source of their confidence in decisively taking the impossibly difficult decisions in the complexities of healthcare where every life and death decision carries risks and side effects. Their self assurance came from within. It came from the absolute knowledge of their objectivity and devotion at a subconscious level. They were absolutely assured that the decision that they took was cleansed of personal interest and selfish emotion. They had been forcibly cleansed of that by practiced indoctrination of the highest medical ethics.
Time limited medicine imposed by administrators and bean counters is the antithesis of absolute, uncompromising medical ethics. Enforcing defensive medicine is enforcing defensive egoism. The deep selflessness that once existed is eroded and lost. The silence of selflessness is lost.
Patients sensed this selflessness. In part, it was expressed as an aura of physical non-verbal communication that they recognised and trusted. However, it was also an intangible presence of greatness that many describe on meeting others who have lived a vocation to the highest level. Certainly it is missed in terms of an aura-like presence that could be trusted absolutely.
This reassuring presence appears to have acted as a placebo. Although the details of the placebo effect are still shrouded in mystery, the basics of the physiology of stress and relaxation are long known to have significant effects on healing, recuperation and disease. These great doctors knew how to massage and entrance relaxation and confidence in a smooth healing process in their patients.
Doctors who have not grasped this subtle psychology of health can inadvertently act as the opposite of a placebo. Rather than giving their patients confidence in their ability to heal, they frighten them into ill health through their verbal and non-verbal communication of their tension and fears.
In the presence of the past master of the clinical arts, all goes smoothly. Most patients run a smooth course. Any problems are predicted and pre-empted.
However, this cannot fully rationalise the well known concept of the ‘lucky’ doctor that dare not be spoken. It is well recognised in medicine that some doctors attract tragedies of health whilst others are assured to have a quiet time of it. Patients that they have never met do not get ill.
I was known to be one of those ‘lucky’ doctors. On call, my urgent work load was a tenth of that of ‘unlucky’ doctors working on the same ward. The ‘unlucky’ doctors just attracted trouble.
So I did an informal study teaching all of the doctors of a surgical unit and introducing them to my state of mind; to calmly desire patients to be healthy rather than to wish to be an all-saving hero. Emergency admissions fell by 90%. The hospital lost the evidence accidentally on purpose for fear of funding cuts or closure.
Now that is a truly mysterious clinical art but many practicing clinicians quietly accept its possibility. The evidence for the lucky doctor with luckier patients is overwhelming. It is just a rational, scientific explanation for the mechanism that is lacking.
That phenomenon I can only record. I cannot explain it. Humanity obviously holds many mysteries that are beyond present science. The past masters of the clinical arts were masters of such human mysteries. They used those mysteries for the health of their patients.
That art is dying. It is being strangled by time limited and rational, medico-legally defensible medicine. It is being replaced by the scientific and mundane. Students and junior doctors have never even heard of it. The gene pool of experience is thinning and will soon be extinct. Only science and technology will remain.
The human satisfaction of medicine and going beyond the call of duty in this noble vocation is being lost. Consequently, the selfless human rewards of medicine are missing as saving a life through individual genius is replaced by machines and algorithms.
No wonder the medical profession is burning out and demanding more societal, egotistical rights. They are demanding normality where once they challenged the limits of human potential.
It is a vicious circle and self-perpetuating cycle.
Can anything be done to break that cycle?
If there is a solution to be found, it will come from understanding the bigger picture of how the mundane and the subtle interact. Medicine is a complex, evolved ecosystem with many interrelated and interdependent levels at play. All these factors must be known and considered rather than fragmenting the greater picture and context.
Non-clinicians and society have interfered again with a complex ecosystem that they did not understand. They had not experienced it. A new generation of doctors has not experienced the traditional ecosystem of medicine as it used to be. They do not appreciate the extraordinary, almost superhuman side of medicine, as created and exemplified by the past masters of the clinical arts. The result is that they have tampered with that delicately balanced ecosystem myopically using a sledgehammer rather than treating it with respect.
It is all about a lack of understanding of the cultural complexity of medicine beyond the mundane and the statistics. Only that understanding can save the highest levels of the clinical arts.
Senior doctors who have tried to defend the old ways need the words and concepts to defend them more effectively and explain the consequences of interfering with the best traditions of medicine, its education and cultural training. They have tried and succeeded in preserving and even institutionalising a few of the very best practices of the past masters, such as the no blame culture of multidisciplinary audit. However, this has only been possible for the more mundane practices and the explicable end of the spectrum. The greatest esoteric arts of the human clinician, the ones beyond science and technology, have been lost.
A central reason that the clinical arts are in decline is that their traditional education and training was unacceptably brutal for modern societal sensibilities. The hours that junior doctors worked were not safe in the context of competitive role differentiation between doctors and nurses. Informally, it was understood that the body of the nursing staff used to be the right hand of the consultant and effectively outranked all junior and middle ranked doctors and provided a second opinion on every decision. The unspoken cultural result of this was a training in both selfless ethics and humility that allowed the exotic states of mind that made the practice of the highest levels of clinical arts.
It was this that allowed the silence to be heard. It quietened the chattering of the ego.
If only it had been understood how and why this harsh training created exceptional human clinicians.
If it can have been explained, perhaps some of the roughest edges can removed and medical education made more palatable. Maybe it can also be made more effective if everybody involved understands its purposes rather than resisting its process because they feel abused.
Knowledge of the real objectives provide the hope that those involved in the medical education and training process will willingly, even enthusiastically participate. Understanding can overcome resistance. Not only can that understanding make the process far gentler but it can also make it far more effective.
Maybe there is some hope for the survival of the highest levels of the clinical arts. There is some hope for the survival of the great contribution that the human clinician can make to patient health by achieving their very highest potential. It is only at that highest human potential that the human being outperforms the machines and protocols and becomes their master rather than their servant.It is the only healthy and productive future for humanity in healthcare.
(I am considering writing a book of experiences and cased studies based on this theme and would welcome any comments and guidance)