Heroes Not Zombies

Montaigne was pretty critical of doctors and the practice of Medicine. You probably think that’s hardly surprising given he lived in the 16th century and wasn’t Medicine a pretty dangerous practice in those days, with harms frequently outweighing benefits. Maybe that’s all changed since those days? With the technological advances of the 20th century doctors have a range of interventions they can use now where the benefits outweigh the harms (for some of the people, some of the time). And at least we don’t bleed and purge patients to death any more, do we?

OK, let me reflect on the current benefits outweighing the harms argument. Let’s deal with harms first of all, because in some ways they are more straightforward. Here’s a couple of interesting facts. Medical interventions are the third most common cause of death in the US. Numbers of deaths decreased when Israeli doctors went on strike. So, there is still plenty of potential for doctors to harm you.

What about benefits? Many infections which previously could overwhelm and even kill patients can now be successfully treated with antibiotics (although we are never far away from predictions that our fifty or so years of success in that area are coming to an end as bacteria adapt, develop resistance to the drugs, and spread that newly acquired ability far and wide). In Surgery there have been enormous improvements. I’ve talked to two patients this week who recently underwent cholecystectomy (removal of the gall bladder) using four small cuts in their abdomens, an extremely short hospital stay and very rapid, complete recovery. Cholecystectomies weren’t like that when I was a young doctor. People having a heart attack who have a clot in a major artery can have it quickly dissolved, or a stent inserted to break through the blockage within hours now. Montaigne’s last two years of life were spent bed ridden, in pain, from kidney stones. You wouldn’t believe how easily that can be dealt with nowadays. I could go on. I’m sure you can add your own examples from your own experience.

But.

There’s a problem. And I don’t mean the harms problem. The problem is that interventions, especially drugs, but surgical ones too, don’t result in the same benefits for everyone who receives them. Roses, of GlaxoSmithKleine, famously gave the game away when pushing the case for pharmacogenomics. He said – We all know that most drugs (90%) don’t work for most patients most of the time (less than 30 – 50%). Why did that statement seem so shocking? Don’t we all know that? Why have all pharmacies got shelves full of drugs which all claim to do the same thing? Whether they are pain relievers, treatments for cold symptoms, allergies, or tummy upsets? Every prescribing doctor will tell you they are glad they have a number of drugs to choose from because no single drug gets the results every time it is prescribed (this is true of EVERY drug, from painkillers, to blood pressure pills, to treatments for asthma, heart failure, epilepsy…..you name it). And here’s where the next aspect of the problem arises. It’s a version of if you give a man a hammer everything will look like a nail. There are drugs and surgical procedures which effectively alter diseases, directly changing the characteristics or behaviours of dysfunctional tissues or organs. (These interventions are often claimed as cures, but I think doctors should retain a little humility here – there are no cures other than through the human being’s capacity to self-heal and self-repair. Treating diseases can increase the chances that self-healing will work, but no drugs or operations directly stimulate or support self-healing.) But what happens when all the drugs tried don’t work? Often one or a number of them are continued, in reality because the doctor doesn’t have anything else to offer. But continuing a drug which is not working tips the balance between benefits and harms enormously. The longer most drugs are taken, the greater the risk of harm. Almost worse than this is that this form of Medicine is used completely inappropriately. Many, many drugs are not prescribed to cure, to heal, or even to control a disease. Instead they are prescribed to reduce symptoms. Reducing symptoms can reduce suffering and whilst we can be supportive of that, it can inhibit dealing with the causes of the symptoms.  However, Palliative care in terminal illness can seriously reduce suffering completely appropriately. But when the cause of the suffering is not addressed, and is ongoing, then a symptom reduction strategy leads to the same problem as the ineffective drug one – the balance tips from benefit to harm.

So Montaigne’s experience and views are still relevant over four hundred years on. Dealing with doctors can be a dangerous experience, and giving them power over you is still not a great idea. I’m of the opinion that the less you have to deal with doctors, the better your life!

When I read some of Montaigne’s comments about doctors, one thing he said which particularly struck me was why don’t doctors have much better health than other people, given they claim specialised knowledge and skills in health?

So, I did some research to see if it was still true that doctors’ health and illness knowledge brings no advantages over others. It’s not entirely true. The famous phenomenon of doctors as an occupational group giving up smoking on reading of Richard Doll’s epidemiological work has resulted in doctors having less smoking-induced illnesses than others. However I can find no evidence that doctors live significantly longer than other people (of similar wealth, race and sex). Nor can I find any evidence that doctors are less likely to suffer from diseases over all.

Looks like Montaigne is right again – if doctors are the experts in health, how come they don’t have healthier, longer lives?